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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 4F;IZ-73 <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/LOCATION 'CENSUS TRACT -' <br /> Owner's Name Phone _z S �� <br /> Address —L,5-" _ Cit <br /> Contractor's Nance License 4t Phone <br /> os <br /> J <br /> TYPE OF WORK (Check) ; NEW WELL J / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Y ow.. . <br /> INTENDED USE TYPE OF- WELL CONSTRUCTION SPECIFICATIONS QQ <br /> i� <br /> Industrial Cable Too <br /> 1 .1 Dia. of Well Excavation ; <br /> Domestic/private Drilled , Dia. of Well Casing %A <br /> Domestic/public- Driven ,— . Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information a <br /> 1 f <br /> PUMP INSTALLATION: Contractor i � <br /> Type of Pump H.P. <br />' PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> i <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 TITLEP <br /> (DRAW P PLAN ON REVERSE SIDE)�4a - V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <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 />