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SAN JOAQUIN LOCAL HEALTH DISTRICT ° <br /> FOUR OFxICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.5= <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1`2f/-7S- <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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( CENSUS TRACT j <br /> e { <br /> Owner's Name . V� Phonak/:::, !�00j <br /> Address - AN City <br /> Contractor's Name Lice e hone- <br /> TYPE OF WORK (Check): NEW WELL / PEN /_/ RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o4 <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Tool Dia. of Well Excavation <br /> Demestic/private y Drilled Dia. of Well Casing _ <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 /> e <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP REPAIR- """"" / / State_Work Done <br />' ,PESTRUCTION 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 o the b f my knowledge and belief. <br /> SIGNED TITLE �. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ C DATE /e 75 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTIQ PHASE III FINAL INSPECTION <br /> INSPECTION BY 3PP DATEINSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRZR T GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />