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q SAN JOA QUIN.LOCAL HEALTH DISTRICT <br /> FOR OFFICE#USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lg -7 <br /> (Complete In Triplicate) <br /> 'Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Viand/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 Distract. <br /> +JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �, 4 n Phone <br /> sAddress <br /> city <br /> [Contractor's Name ��nw� -. License !r? �Phone <br /> STYPE OF WORK (Check) : NEW WELL j /1 DEEPEN '/ // RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / w- PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other. / / <br /> }DISTANCE TO NEAREST:' SEPTIC TANK �' � SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD <br /> CESSPOOL PIT OTHER <br /> s <br /> INTENDED USE TYPE OF WELL "' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - Dia. of Well--Excavation <br /> as Domestic/private Drilled Dia. of Well Casing t1 <br /> Domestic/Public ` Driven Gauge,of Casing Cl <br /> Irrigation Gravel Pack ­Depth .of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information 1 <br /> gFUMP INSTALLATION: Contractor <br /> f Type hof Pump _ H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIRState Work Done <br /> _DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <br /> • � l 1 <br /> I hereby agree to comply with all laws and regulations of . the San Joaquin Local Health District <br /> and the State of Californialpertainin_g to_ or regulating well construction. Within FIFTEEN DAYS <br /> i after completion of my work}on .a3new 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 /> t <br /> SIGNED TITLE <br /> (DRAW PLOt PLAN ON REVERSE SIDE-4- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> E <br /> '+. APPLICATION ACCEPTED BY DAT _ <br /> ADDITIONAL COMMENTS: + INSPECTION <br /> PHASE II GROUT INSPECTION P. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />