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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf.:OFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- 7 3l <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued & 0 7 7 <br /> (Complete In Triplicate) <br /> Application is hereby rude to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is wade in compliance with Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Eieal.th District, <br /> JOB ADDRESS/LOCATION _ 7 � / �1� �/ - CENSUS TRACT <br /> 'Owner's Name / , /'-rte Phone <br /> Address E ,�� V,<CtXWV �_ City , f�1 <br /> Contractor's Name � ��p- �( -_ - - --__ License #111 1)71 Phone '' ,j <br /> TYPE OF WORD (Check) : NEW WELL / I DEEPEN '/ / RECONDITION / / DESTRUCTION AL / 1� ; <br /> PUMP INSTLATION I I PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j <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 /> I <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP `tEPAIR: / J State Work Done <br /> .DFGTRUCTION 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 ak <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 any knowledge and belief. <br /> SIGNED TITLE j�1/rti ,C <br /> (DRAW -PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTFIENT USE ONLY <br /> PHASE I �. .- . <br /> APPLICATION ACCEPTED .BY DATE 1297 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION .BX DATE INSPECTION BY /°, DATE /1 -,f '77 <br /> --CALL-FOR-A�GROUTINSPECTION.-PRIOR-TO GROUTING AND -FINAL INSPECTION. _.... <br /> IT 4 1., ff 17 Z, a <br />