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SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> F R OFFICE USE; 1601 E. Hazelton�Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'s_/�$� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued /per <br /> (Complete In Triplicate) <br /> aide to the San Joaquin Local Health District for a permit to construct <br /> Application is hereby m <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 a 3 CENSUS TRACT <br /> Owner's Name 's ems' �' S <br /> Phone <br /> Address <br /> City <br /> DLJ <br /> Contractor's Name r_e� License # I f `7xrPhone VZo.i- <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /? RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION /7 PUMP REPAIR / PUMP REPLACEMENT i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P1T PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />_ industrial Cable Tool Dia. of Well Excavation <br />_ _ Domestic/private 4-1Drilled..,- .� _ 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 /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure ----------�- <br /> L hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> tnd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Lfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before utting the well in use. The above <br /> information is true to the best of my knowledge nd`bel e . <br />!IGNED LE <br /> DRAW/PLb PLAN ON REV� <br /> E �V SIDE <br />'RASE I E4 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III F AL INSPECTIQ <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 _ 7/72 1M <br />