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W SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> J170£_ OEI"xCLUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> — APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6 SZ/0 A <br /> r ; 76- 7S-P� <br /> THIS- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Qr/2-76 <br /> (Complete In Triplicate) <br /> App ication is hereby made to the San 'Joaquin Local. Hearth District for a permit to construct <br /> a /or iI the work herein described.., This application is made i,n compliance with San Joaquin <br /> u y Once No. 1862 and the Jules $ Reaulations of the San J'oa in Local Health District. <br /> 9DRFi, )1,OCATI6NCENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address / .' City <br /> Contractor's Name <br /> '..R License/#�Phon� <br /> ,1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /-J ., <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> U then- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />{ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q , <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled. Bio. of._Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I� <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> G : State Work Done <br /> PUMP `ZEPAIR: I <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well°Diameter <br /> + Describe Material and Procedure <br /> 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 r TITLE 't <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I DATE -7 <br /> APPLICATION ACCEPTEDmBY <br /> ADDITIONAL COMMENTS: <br /> PHAS I 'GRO T INSPECTION PHASE L FINAL INSPECTION <br /> INSPECTION BY EGROUT <br /> �JDATE — INSPECTION BYDATECALL FORA SPECR10R TO GROUTING AND FINAL INSPECTION. 73 1M <br /> i.3 0 pm 5/ <br />