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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR (fiFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7Z--77 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued 7-Z -7?/ <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 Ordinance o. 1862 and the Rules and Regulations of the San J aquin Local Health District. <br /> .TOB ADDRESS/LOCATION C � � � '�O CENSUS TRACT <br /> Owner's Name _ L Phone ' <br /> Address .-_ � Q�J City -- 1 P0 <br /> Contractor's Name NAlf A16ca _ 13A Q License # Phone <br /> t l 1 f, . y i� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / /�� RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION .2WPUTMP REPAIR / / PUMP REPLACEMENT /? <br /> ) Other <br /> DISTANCE TO NEAREST: /I SEPTIC TANK SEWER LINES SPIT PRIVY <br /> "SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PId&L%fF—rOTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privato. Drilled Dia, of Well Casing <br /> mestic/ ublic <br /> _ _�� p riven Gauge of Casing 3 <br /> Irrigation ?Gravel Pack Depth of Grout Seal <br /> Other E�� Rotary Type of Grout - �.-r •- -- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor PIPPAL <br /> ' Type of Pump C • i.1 i j i S i i H.P. <br /> PUMP REPLACEMENT: ( / / State Work Done <br /> -t <br /> PUMP REPAIR:. --� / /--State Work Done <br /> ,DESTRUCTION 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 is true to the best of my knowledge and belief. <br /> SIGNED = , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT IJSE ONLY _ . _. <br /> PHASE I <br /> APPLICATION ACCEPTS DATE <br /> ADDITIOIJAL�-C&ft TS: - . _ .. <br /> P S GROUT INSPECTION FINAL INSPECTION <br /> INSPECTION,.�B - : i DATE t / . ; NSPECT;ON,BY DATE �� 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 4/72 1M l <br />