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SAN JOAQUIN LOCAL IIEALTIT DISTh <br /> FOR OFFICE USE: X601 E. Hazelton Ave. , Stockton, Galif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRiICTION OR P PE I <br /> mit No. �- 76 Z-- <br /> THIS <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED : <br /> Da . Tssued �� <br /> �,+ (Complete In Triplicate) <br /> ,: <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 applic <br /> County Ordinance No. 1$62 and the Rulation is made in compliance with San Joaquin <br /> f es and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ' CENSUS TRACT - <br /> Owner's Name r <br /> �. Phone3/ 7 2 6-- <br /> Address <br /> City <br /> Contractor's Name oe License # <br /> �132 Phone ` <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION / <br /> _ —7 DESTRUCTION /_7 <br /> PUMP INSTALLATION jo - PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> F_ <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PIT PRIVY <br /> SEWAGE ;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustriaCONSTRUCTION SPECIFICATIONS <br /> l 1 Cable Tool Dia, of Well Excavation .� <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> X Irrigation i Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: i I — <br /> / / State Work Done <br /> PUMP REPAIR: I <br /> State Work Done <br /> MTRUCTION OF WELL: Well Diameter <br /> �— <br /> Describe Material and ProcedureApproximate Depth --�-------- <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 <br /> TITLE w <br /> + DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMEDATE <br /> NTS: r <br /> P— .II GROUT INSPECTION PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � ,� DATE <br /> CALL- FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �1 <br /> 4/72 1M <br />