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/Y�-_.._.�` <br /> S SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ZOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: • W.9)-I,466-6781 f <br /> APPLICATION FOR WELL CONSTRttCTION OR PUMP PERMIT Permit No. - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> t ;I (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 /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> � f <br /> JOE ADDRESS/LOCATION �S� �� CENSUS TRACT <br /> Owner's NaPhone <br /> Address ` <br /> City <br /> I 7 <br /> Cottractor's Name License .j"��p7'Phone a/,/ <br /> t TYPEOF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_ DESTRUCTION / <br /> _ /_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Otheri /% <br /> DISTANCE TO NEAREST; SEPTIC[T_ANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> IIII INTENDED USE TYPE —OF-WELL CONSTRUCTION SPECIFICATIONS <br /> p. Industrial Cable Tool Dia. of Well Excavation <br /> 1 Domestic/private/p ivate t Drilled Dia.TMof-Well Casing <br /> Domestic/public' p I Driven Gauge of Casing � ! <br />` .1I. Irrigation 41 Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information} <br /> PUMP INSTALLATION: Contractor " <br /> Type 6f. Pump 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 /> E I h reby agree to comply wits all laws and regulations of the San Joaquin Local Health District <br /> andlithe 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 <br /> th <br /> SIGNED best of my •knowledge and belief.. <br /> 11l �� ' <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> r PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />{ ADDITIONAL COMMENTS: , 1 <br /> I� PHASE II GROUT INSPECTION PHASE III/FINAL IN <br /> INSOPECTION BY DATE INSPECTION BY T <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> Al. <br /> E H 1426 .7,11 <br /> 7/72 IM_ - <br /> .. <br />