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• i <br /> 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.,3 6-1 5� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //. o-J.3 <br /> r 3 77"' jl (Complete In Triplicate) �� �o�-lc (/ <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 Regulati of the San Joa uin Lo 1 Health District. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Phone �_� 7,/P6 <br /> Ir <br /> --Cit C Ct <br /> Address - <br /> Contractor's-Name License e 03 Phone <br /> TYPE OF WORK .(Check) : NEW ,WELL/ /..DEEPEN /7RECANDITION DESTRUCTION /� 1 <br /> k - PUMP INSTALLATION PUMP REPAIR'// PUMP REPLACEMENT <br /> Other <br /> i <br /> DISTANCE TO. NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ,SEWAGE DISPOSAL FIELD CESSPOOL/SEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL -.,,CONSTRUCTION SPECIFICATIONS <br /> - Industrial- Cablb Tool Dia. of>,Well Excavation <br /> Domestic/private;. " `,�--Drilled Dia. of Well Casing r <br /> Domestic/public'X 4 Driven Gauge of-Casing-' <br /> Irrigation 'Gravel Pack Depth of Grout Seal i <br /> Other . ' ' # „ � 3..� Rotary Type of Grout <br /> Other Other Information" <br /> l PUMP INSTALLATION: -CZ ntractor <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> _. <br /> r--PUMP `REPAIR-:• /-'/""S-ta�e-Work�Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth' <br /> � <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 /> inform tion is true to be knowledge and belief. ' <br /> SIGNED \ TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ZAPPL <br /> =-- <br /> ` <br /> PTED BY " DATI <br /> ADDITIONAL COMMENTS: <br /> PHASE II IN ECTION .PHASE III FINAL INSPECTION.,.. <br /> INSPECTION BY DATE ,,INSPECTION BY <br /> CALL FOR A GROUT. SPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M <br />