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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,: 01R;SFFICE USE: 1601' E. Hazelton Ave.:, .Stockton:, Calif. <br /> Telephone: t (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR.PU.1P PERMIT Permit No. 7 Z- <br /> �t THIS PERMIT EXPIRES. 1- YEAR. FROM-DATE. ISSUED Date Issued I l 77, <br /> (Complete In Triplicate) P £ # <br /> Application :iso e' reby-made.;to :the, San_.Joaquin Local Health District for a permit to construct <br /> and/or instal1l. the work herein described. This application -is made in compliance with San Joaquin <br /> County Ordinance-No-.---.1862 and th ulesrand Regulations of the San Joaquin Local,Health District, <br /> JOB ADDRESS/LOCATION E CENSUS TRACT ' <br /> Owner's. Names^ ; .Phone 6 tO <br /> Address City <br /> Contractor's Name 4 License d Phone 6 - Y,7 <br /> TYPE OF WORK (,Check) : NEW WELL / DEEPEN '/-7 RECONDITION /-7 DESTRUCTION./7 � .. ,,..► .. <br /> PUMP INSTALLATION / / 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 /> 4 <br /> INTENDED' USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - Dia. of Well Excavation <br /> Domestics/private Drilled Dia. of Well Casing ] <br /> Domestic'hublic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 4 <br /> [ Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> r` Type of Pump <br /> PUMP REPLACEMENMT: / / State Work Done <br /> PUMP REPAIR: /�/ State Work--Done=- "" <br /> .DESTRUCTION OF, WELL: Well Diameter Approximate Depth <br /> " Y Describe Material and Procedure T �" <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 /> S ' <br /> SIGNED TITLE <br /> :R (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY ( DATE (f-16 <br /> :ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '7 <br /> CALL FOR A$GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />