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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 3.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z /zl <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED Date Issued <br /> 1, (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 /> , I <br /> JOB ADDRESS/LOCATION ± T� 12 CENSUS TRACT <br /> Owner's Name ' Phone <br /> Address city <br /> Contractor's Name �� `� <br /> License 4� Z, 322 Phone ' S <br /> t <br /> TYPE OF WOkk (Check) NEW WDLL^ /F,_7' DEEPEN %_/ RECONDITIONI_7 ESTRUCTION - <br /> 17_.Y <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /_7 <br /> Other-1/ / c <br /> I � <br /> DISTANCE TO NEAREST: SEPTICiTANtC SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation -' <br /> s <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> Other Other Information E <br /> PUMP INSTALLATION: Contralctor 41 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> _ / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall 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 } <br /> • �- • �lac1. TITLE <br /> (DRAV PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> , ' <br /> APPLICATION ACCEPTED BY - ' DATE <br /> ADDITIONAL COMMENTS: y <br /> PHASE II GROUT INSPECTION PHASE III/FINAL_INSPECTION r <br /> INSPECTION BY DATE INSPECTION BY DATE-,,r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC IO <br /> E H 1426 7/72 IM <br />