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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 /> (Complete In Triplicate)T <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 /> r <br /> County Ordinance No. 1862 and the Rules and Regulations .oi the San ,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION z yy .S': /7<y�,.. _ ()./� CENSUS TRACT <br /> Owner's Name <br /> Phone 23 - <br /> Address �. City ��'i �- --- <br /> Contractor's Name C_ License # ,746OZ Phone 4 <br /> TYPE, OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <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 Cable Tool Dia. of,Well- Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - IrrigationsGravel Pack Depth of- Grout Seals <br /> Other Rotary 'Type of Grout ,. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ✓ y <br /> Type of Pump H.P. F <br /> .� t <br /> PUMP REPLACEMENT: / / State Work Done � .. <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF <br /> WELL.: Well Diameter � ' .7 _. Approximate Depth <br /> - <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-tne best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �'� a .. DATE. <br /> ADDITIONAT. <br /> PHASE II UT INSPECTION `" PHASE 41INAL INSPEC ION <br /> INSPECTION BY� DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4 <br /> .H .H 1426 7/72 1M <br />