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rr <br /> i 3 �. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT W <br /> Fflt O11ICE U5L: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465--6781 <br /> 'Ap ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77 <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE:ISSUED Date Issued / " —— 77 <br /> (Complete In Triplicate) <br /> Applicdtion is hereby rriade to theSanJoaquin Focal Health District for a permit to -construct <br /> anal/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance ,No. 1862: and_t�e. Rules and Regulations of the San Joaquin Local 1tealth District. <br /> E <br /> JOB ADDRESS/LOCATION " : RACT <br /> Phone <br /> i Owner's Nasse <br /> ti <br /> Address - r City <br /> _ <br /> License /7�Phon e <br /> Contractor's Name <-- <br /> E� <br /> TYPE OF WORK (Check).: NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 �; <br /> PUMP INSTALLATION �PUMP REPAIR'El PUMP REPLACEMENT <br /> i Other <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 /> {I Industrial.- r Cable Tool Dia. of Well Excavation <br /> I Domestic/private .. .Drilled Dia. of Well. Casing <br /> €€ Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal .� <br /> Other , _ _x Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> g <br /> PUMP REPLACEIeSENT: / / State Work Done <br /> _ 1 <br /> PUMP 'REPAIR: / / . State Work Dore <br /> DE TRUCTION 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 we11 ''construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District <br /> � <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> `k information is true to -the best of my knowledge and belief. <br /> i <br /> TITLE <br /> SIGNED <br /> ('+ , . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMNTS: . <br /> PHA I GR UT INSPECTION PHASE FIN INSPECTION r <br /> a INSPECTION BY DATE T=�_ 7 7 INSPECTION BY DATE <br /> 4 <br /> . CALL-FOR A GROUT 'SP CTION-PRIOR TO OiITING D FF�I/(JJY���7AALL�}INSP�/E/)CTION. 7 / /� 1H <br /> — LF 1 L°3 G �V ' �'Pw — �/ �� / • '� e { /'1 .L1 l - <br />