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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF—W.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-7-5-41Z74,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssUed g-.zu-7_3 <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 Sart Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the Sart Joaquin Local Health Dis4rict. <br /> JOB ADDRESSJLOCATION <br /> � C / CENSUS TRACT <br /> Owner's Name � `� �T-��� ------ - - Phone/a <br /> Address C� � ��_�-j/ '� City 105 =1le�flll Mf <br /> Contractor's Name �� �� � , � License # 1�,2 3?3 Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION / / DESTRUCTION 1-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 60 CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI9�§ <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -70_ 1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout.(7. � <br /> Other Other Information V <br /> PUMP INSTALLATION: Contractor _ " <br /> Type of Pum �7r" eJ 1y H,P. , <br /> PUMP REPLACEMENT: / / State Work Dona <br /> PUMP UPAIR: / / State Work Done <br /> ,DF",TRUCTION 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 knowledge and belief. <br /> SIGNED - , --j TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I ,� <br /> APPLICATION ACCEPTED BY .. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,fes DATE /O -Zti— <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _ E x 1426 5/731M <br />