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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` FOR OFFICE-USE: 9d -1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77y <br /> k �! THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued27 <br /> i� (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 Joaquii <br /> ' County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J CENSUS TRACT <br /> Owner's Name Phone <br /> Address City zw-o= <br /> Contractor's Name License #/7ZV/Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PYMP REP CEMENT <br /> Other I <br /> DISTANCE TO NEAREST: SEPTI ANK R LINES PIT PRIVY <br /> <: SEWAGE DISPOSAL IOEEID CESSPOOL/SEEPAGE PIT OTHER Q, <br /> INTENDED USE i, TYPE OF WELL CONSTRUCTION SPECIFICATIONS ~" <br /> ' Industrial ii Cable Tool Dia. of Well Excavation °c <br /> Domestic/private; Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigat Gravel Pack Depth of Grout Seal - <br /> h Other Rotary Type of Grout <br /> Other Other Information <br /> it <br /> u <br /> PUMP INSTALLATION: ( Contractor .�.., <br /> Type of Pump H.P. S <br /> PUMP REPLACEMENT: State Work Done <br /> I <br /> PUMP REPAIR: / / State Work Done <br /> L -Depth-- <br /> , ,DESTRUCTION <br /> OF WELL: Well Diameter App=oximate <br /> :i 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 myi;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 I1.the best of my knowledge and belief. <br /> .�3 vrf'� <br /> SIGNED '` -j TITL <br /> (MW 7LOT PLAN ON REVERSE 5 ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE �:� �� 7 <br /> FADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> ( INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 " 7/72 1M <br />