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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 /> 77��,J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �p <br /> (Complete In Triplicate) <br /> Z�5y_ <br /> __; <br /> Application ie 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 d Regulations of the San, Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> { Owner's Name o Phone 3 3 2 <br /> Address <br /> S City <br /> Contractor's Name L License # �n P <br /> CO3 hone ' ,,p3-9 <br /> k TYPE OF WORK (Check) : NEW WELL / DEEPEN /_7 RECONDITION /T DESTRUCTION /_7 - �q <br /> PUMP INSTALLATION /Lq__7UP REPAIR / / PUMP REPLACEMENT / 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER L�NES _ 1 PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD _CESSPOOL/SEEPAGE PIT/fgn�, _OTHER _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation [� <br /> �stic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Other Gravel Pack Depth of Grout Sea f <br /> 4i� 6tary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION*. Contractor <br /> Type:_of *Pum H.P. <br /> 3. <br /> PUMP REPLACEMENT: / / ' State Work =Done <br /> 1 <br /> IPUMP REPAIR: - / / State Work Done <br /> d _ _ <br /> ,DESTRUCTION Ok WELL': Well^Diameter , Approximate Depth 4.1. <br /> Describe Material and Procedure i <br /> I hereby agree to.comp.ly with all laws and regulations of the San Joaquin Local Health District ',,- <br /> and theState of Cali.fornia'per.taining 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 REPDRT. of .f he well_arid'notify them before putting the well in use. The above <br /> infor ion is true .to the- est(o knowledge and belief. <br /> SIGNED <br /> _ TITLE <br /> PLOT PLAN ON REVERSE SIDE) 's— <br /> PHA I F R DEPARTMENT USE ONLY <br /> .r• t <br /> APPLICA CCEPTED BY DATE ° <br /> ADDITIONAL COMMENTS: <br /> el <br /> PHASE II GR P I PHAS I .FINAL INSPECTION <br /> INSPECTION BY D INSPECTION BY <br /> CALL FOR A GROUT IN ECTION PRIOR TO GROUTING AND FINAL,-INSPECTION. <br /> E H 1426 <br /> �' � :. .. �. .. 7/72 iM <br />