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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 <br />THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />Applicationishereby made to the San.Joaquin Local Health District <br />and/or install the work herein described. This application is ma <br />County Ordinance No. 1862 and 11 -the Rules and Regulations of the San <br />JOB ADDRESS/LOCATION _ G%_ <br />Permit No. /'a-//3 <br />Date Issued <br />t <br />for a permit to construct <br />in compliance with San Joaquin' <br />Joaquin Local Health District. <br />Owner's Name �i5rr <br />Address `� o`k J� <br />Contractor's Name License # <br />CENSUS TRACT <br />Phone <br />City <br />Phone <br />TYPE OF WORK (Check): NEW WELL / / DEEPEN I / RECONDITION /-7 DESTRUCTION l -„T <br />PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT/ -7— <br />Other.! ` <br />DISTANCE TO NEAREST: SEPTIC.S PIT PRIVY <br />SEWAGE�DISPOSAL FIELDTK WER LINECESSPOOL/SEEPAGE PIT OTHER <br />f � <br />INTENDED USE <br />Industrial <br />Domestic/private <br />Domestic/public <br />Irrigation <br />- Other _ <br />PUMP INSTALLATION-. <br />k PUMP REPLACEMENT: <br />PMV REPAIR: <br />I DESTRUCTION OF WELL: <br />TYPE OF WELL <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />Contractor _ <br />Type of Pump <br />CONSTRUCTION SPECIFICATIONS <br />t <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Informationtr <br />o~ <br />3 <br />H. P. <br />State Work Done <br />i <br />State Work Done <br />Well Diameter Approximate Depth <br />Describe Material and Procedure <br />I hereby agree to comply with alI 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 />PHASE I /f <br />, APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />f INSPECTION BY DATE <br />TITLE <br />PLOT PLAN ON REVERSE SI <br />FOR DEPARTMENT USE ONLY <br />INSPECTION By <br />E III <br />DATE <br />INAL INSPECTION <br />,M , DATE IF- a <br />CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 IM (1J <br />E H 1426 <br />