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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EDT'. OFFICE USI,: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209). 466-6781 77-7&(o rc} � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � �� <br /> I <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-a.5-77 <br /> i <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 Nos 1862 and the. Rules and Regulations. o£ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name jL414" - - - „... Phone ; <br /> Address fe� C�14-1 City <br /> Contractor's Name �� License ��Phone <br /> j <br /> TYPE OF WORK (Check) : NEW. WELLYDEEPEN /_/ RECONDITION / ./ DESTRUCTION /-7PUMP INSTALLATION / / PLW REPAIR / / PUMP REPLACEMENT /-7 ^� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDER USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private.Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing aL. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout i <br /> Other Other Information ; <br /> PUNT INSTALLATION: Contractor - <br /> Type of PumpH..P. <br /> PUMP REPLACEMENT: ,�J State Work.Done <br /> PUMP UPAIR. State Work Don <br /> P �4,Qi�N�orv�� <br /> OF WEL Di m ter e4,fR�TRUCTTON ��Approximate Depth <br /> .,.. ... <br /> 'De•sr be Material and Pro educe - <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 'construttion. 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 V <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEZ--�4-- -.7 <br /> ADDITIONAL COx',MENTS: <br /> PHASE II GROUT INSPECTION P S /FIN INSPECTI € <br /> INSPECTION BY DATE 7 z INSPECTION BY ZV4 DATE 7r <br /> CALL-FOR A/.GROUT INSPECT17- <br /> ON -PRIOR .TO GROUTING,.AND .FINAL. INSPECTION. 1T <br /> 7 U IA79 ALl.��r��r/ 7 7_7- /•7 7 /_ .PA.i_ 1 /}Q r I2 <br />