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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFIICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> --- 'Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7��-5 ,3 <br /> THIS, PERMIT .EXPIRES l YEAR FROM DATE ISSUED Date Issued 7-fig-76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> This application <br /> is made in compliance with San Jbaqui.n' <br /> and/or install the work herein described. PP <br /> and Regulations-Of the San Joaquin Local Health District. <br /> County Ordinance No.: 1862 and the Rules <br /> CENSUS .TRACT , <br /> JOB ADDRESS/LOCATION CZ110 - <br /> Phone ' <br /> Owner's Name <br /> Q City . . <br /> Address <br /> License �� !Z <br /> Contractor's Name <br /> Phon� <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN '/ / RECONDITION_/ALDESTRUCTION <br /> / I� i <br /> PUMP INSTLATION /�/ PUMP REPAIR/ / U' <br />'4 Other <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL \n <br /> Industrial Cable Tool Dia. of Well Excavation _ \' <br />� <br /> Drilled ..RT��-=-Dia•=of-Well-Casing " f p�/ .Domestic/private a <br /> '- Gau of Casing <br /> Domestic/public 1. Driven g g <br /> irrigation f Gravel Pack Depth of Grout Seal m <br /> r Other Rotary Type of Grout <br /> Other Other Information <br /> _ix <br /> PUMP INSTALLATION: Conticactor H.P. <br /> 1 Type of Pump <br /> {t PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done \ <br /> Approximate Depth <br /> DFRTRUCTION OF WELL: Well Diameter <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 an 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. 4 <br /> TITLE ._ <br /> SIGNED <br /> � DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE f —� <br /> APPLICATION ACCEPTED BY 74 <br /> 'i ADDITIONAL COMMENTS: PHAS /FIN INSPECTION <br /> 4.. PHA,S GROUX INSPECTION / ATE • 711 <br /> INSPECTION BY DATE -Z 6 Y Ufa INSPECTION BY <br /> -CALL FORA-GROUT INSPE TION PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> 5/73 <br />