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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F R OF____: = <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -SS 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM, DATE ISSUED Date Issued 7/_76 <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 Joaquiv <br /> County Ordinance No. 1862 and the Rules and gulation of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCA ON CENSUS TRACT <br /> � .. <br /> Owner's Na <br /> Phone <br /> i Address City <br /> I <br /> Contractor's Name License #1,0140� Phone <br /> TYPE OF WORK (Check) : NEWW_ELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INS LATION / P <br /> Other <br /> � REPAIR / I P REPLACEMENT f <br /> •�''_— <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHEV��O l v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public Driven Gauge of Casing <br /> r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other j Rotary Type of Grout 1 <br /> Other Other Information �! <br /> PUMP INSTALLATION: <br /> Contractor y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / ! State Work Done <br /> PUMP REPAIR. / 1 State Work Done <br /> C <br /> I .pESTRUCTION OF WELL: Well' Diameter Approximate Depth ` <br /> Describe Material and Procedure <br /> r k � <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 E <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 TITLEWE <br /> (DRAW-PLOT PLAN ON REVERSE SI <br /> R DEPARTMENT USE ONLY <br /> PHASE I APPLICATION ACCEPT DATE 7- 7-76 r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E I Z INAL INSPECTION <br /> INSPECTION„BY DATE INSPECTION BY DATE �(cl <br /> CALL FOR AAGROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> B H 1426 7/72 1M <br />