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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .I (Complete In Triplicate) Y <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 the34zc , <br /> and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CO�� CENSUS TRACT <br /> NameOwner's Nae Phone 9 <br /> Address 3/,r' <br /> Contractor's Name _ License # Phone <br /> o G�� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_% RECONDITION /7 DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 3 <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 I Cable Tool Dia, of Well Excavation . <br /> Domestic/private Drilled Dia. of Well Casing rl <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> t Other Other Information <br /> + �� M <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump <br /> f H.P. / <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter 1 <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 t best of my knowledge and belief. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M ` ! <br />