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. 111601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �0�'. di� ICL USE; E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 514 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � Z) <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 tfie 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 -- �r�,R.� , `� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License Phone g3f=jay <br /> TYPE OF WORK (Check) : NEW WELL f / DEEPEN !_/ RECONDITION I / DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other2�� u <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 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 <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done Y <br /> PUMP UPAIR: f f State Work Done <br /> i DFgTRUCTION 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 k wledge and belief. ` <br /> SIGNED TITLES <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> F APPLICATION ACCEPTED BY �, -�� y�� DATE Y -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL I'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 5/731M <br />