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x DSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ZZ"1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,3sy�7r/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 73 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for 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 /> JOB ADDRESS/LOCATION w. CENSUS TRACT <br /> Owner's Name. Phone <br /> Address t City <br /> Contractor's Name & License 4llhlo3) Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INS LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - '.' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing X <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 's <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR;. / / State Work Done <br /> J)ISTRUCTION- OF WELL: Well Diameter 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 TITLE ?1.P <br /> _ ._ DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEyXqMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACC5RZE& BY - DATE <br /> ADDITIONAL ABW <br /> IT <br /> INSPECTION P T AL INSPEC I N <br /> INSPEC N DATE INSPECTT DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ! <br /> E H 1426 7/72 1M <br />