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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.7 3-S10 60 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $ <br /> (Complete In Triplicate) C7s'!- C C6a 30 <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name C <br /> Phone 9 J I <br /> Address <br /> City <br /> Contractor's Name License #/Ga j�3 Phone <br /> TYPE OF WORK (Check) :' NEW WELL DEEPEN /_` RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION ,/S PUMP REPAIR / / PITMP REPLACEMENT /7 <br /> Other /_/ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES f_ro I PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �200 CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of' Casing <br /> Irrigation Gravel Pack Depth_ of Grout Seal VIC <br /> Other Rotary Type of Grout <br /> Other Other Information ~ <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter .� Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all 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 I TITLE <br /> .. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 017/`7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <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 />