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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 S`Sd <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ///Y_73 <br /> {Complete In Triplicate) <br /> Application is hereby tide 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 Sax Joaquin <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Localllenith District. <br /> ;z ! CENSUS TRACT <br /> JOB ADDRESS/LOCATION �'Z� <br /> .. Fhonecc, <br /> Owner's Name <br /> 1. l 4- ( ti City , . <br /> Address <br /> Contractor's Name <br /> License J 2 6Phone7rL <br /> TYPE OF WORK (Check): .11,NEW WELL / i�C�EPEN -/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT j� <br /> AL <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a* <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private. Drilled Dia. of Well Casing /Z) <br /> Domestic/public '' Driven Gauge of Casing <br /> �Ixrigation <br /> �' Gravel Pack Depth of Grout Seal <br /> Other a Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H`P' <br /> PUMP REPLACEMENT. / State Work Done <br /> - <br /> - <br /> PiJ T 'tEPAIR: / / State Work Dane <br /> ,DFgTRt1CTION OF WELL: " Well Diameter Approximate Depth <br /> i <br /> ,, .Describe Material and Procedure <br /> I hereby agree t® comply with ail 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 /> TITLE <br /> SIGNET (DRAW PLOT PLAN. ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> k PRASE I \ <br /> APPLICATION ACCEPTED .'BY \ DATE /�/Sl3 <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 /> 5/731M. <br /> E H 1426 <br />