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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: '' _ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued -77/ <br /> (Complete In Triplicate) <br /> Application is hereb 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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �f 3'73 E . Tei T ' , 0'0s-- / (oma - D <br /> JOB ADDRESS/LOCATION o CENSUS TRACT <br /> Jf <br /> Owner's Name Phone1- <br /> Address .2 Lr tf _ ��C,c I - -- r. ,.-sem City <br /> IV <br /> Contractor's Name - - ,�,� .r License #10-3]3 Phone <br /> , <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> ALREPLACEMENT- 1-7 <br /> / fl `iii <br /> PUMP INSTLATION PUMP REPAIR - PUMP REPLACEMENT /-7 <br /> Other / / (N <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor :� 4 f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _ DW- State Work Done. <br /> .DEST_R_U_CTION 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information iZ;i;= <br /> true knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �`! _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> • yy <br /> F <br />