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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF.n:OF ICE USE: 1601. E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) -466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77- �2 3J 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3/1' 77 <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 Ordinazice No.. 1862 and the Rules a d egulations of the San Joa ui l Lor-al Fle,�t.,th Pi ri t. <br /> JOB ADDRESS/9 TION ,'� A US TRACT <br /> Owner's Name KQ.[�4�U— p,�n �Yr,C� - _ Phone r, <br /> Address City <br /> Contractor's Name License Q7 ho <br /> TYPE OF WORK (Check): NEW WELL/X DEEPEN/ / RECONDITION / { DESTRUCTION {? <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /TT <br /> 0 Cher / — - — <br /> DISTANCE TO NEAREST: SEPTIC TALK 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 /> omestic/private Drilled Dia. of Well Casing <br /> omestic/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 R.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> DFGTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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 try knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) { <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE I ® 7 <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMIINTS: <br /> PHASE GROUT, INSPECTION PHAS I /FIN L INSPECTION <br /> INSPECTION BY DAN//P <br /> TE (` 7 7 SPECTION BY ji ATE 2-- —7 <br /> cc i <br /> CALL FOR A GROUT I SP TION P�IO& AOR TING D FINAL INSPECTION. <br />