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-- SAN JOAQUIN LOCAL HEALTH DISTRICT < <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,?,2- `" V <br /> THIS PERMIT EXPIRES I YEAR FROK DATE ISSUED Date Issued <br /> (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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATIONQ QQ�{]/'i �' CENSUS TRACT S <br /> Owner's Name , Phone 4%f-Q� •- <br /> Address G, I''i� City <br /> f # <br /> Contractor's Name '1e License # Phone <br /> — r <br /> TYPE OF WORK (Check). NEW WELL f ` DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 } <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other i-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK;� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRICTION SPECIFICATIONS _ <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> T� Domestic/private Drilled Dia. of Well Casing �Q _ J a <br /> Domestic/public Driven Gauge of Casing <br /> JZ Irrigation _ Gravel Pack Depth of Grout Seal D <br /> Other Rotary Type of Grout <br /> Other Other Information Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 5. <br /> PUMP REPLACEMENT: / State Work hone <br /> PUMP REPAIR: / / State Work Done <br /> i - - <br /> !,DESTRUCTION 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 TITLE <br /> (57 (DRAW PLOT PLAN ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Z--2S-'2 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Akw <br /> E H 1426 7/72 1 <br />