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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :p (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 <br /> 7-7 <br /> (Complete In Triplicate) 0 _V3o <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �f(a3lQ F_ . �LeP-/_ <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address _ � � Cityr <br /> Contractor's Naas � <br /> - ��p ... ��' License Phone3 <br /> TYPE OF WORK (Check): NEW WELL /_7 / RECONDITION /_7 DESTRUCTION /_7 Y <br /> PUMP INSTALLATION _/ / PUMP REPAIR , PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT Gv <br /> OTHER 6\ <br /> INTENDED USE TYPE OF WELL �' <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> - -- Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other,,Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. / <br /> PUMP REPLACEMENT: /'/ -State-Work Done <br /> PUMPREPAIR: ' <br />- �' State Work Done�,u,(� - ✓�,�.. _ _. _ .� <br />,DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the, well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> L64_-14`711 �,4 <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE r <br /> PHASE I n <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �[ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE .' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> /72 1M <br />