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SAN JOAQUIN LOCAL HEALTH DISTRICT D f <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. l <br /> Telephone: (209) 466--6781 �L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No77_1P_ / <br /> 44a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10j&7, ! <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 <br /> Phone S <br /> Address ' City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL ./—/ DEEPEN /7 RECONDITION FT DESTRUCTION 17 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> a. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION `SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation pp <br /> Domestic/private Drilled Dia. of Well Casing `V <br /> Domestic/public Driven Gauge of Casing p ; <br /> Irrigation Gravel Pack Depth of Grout Seal �r <br /> Other Rotary Type of Grout <br /> Other Other Information 4 <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: h / / ' State Work Done t <br /> ESTRUCTION OF WELL: Well Diameter <br /> �_ 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 o£. 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 <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 /> DIM-PLOT PLAN ON REVERSE SID9f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Z,7 DATER a <br /> ADDITIONAL COMMENTS: <br /> PHASE I r ROUT INSPECTION PHASE III4KINAL INSPE51ION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND 'FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />