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e <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. 01 k ICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k Telephone: (209) 166-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-1-/5-76 <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 No. 18162 and the Rules and Regulations of the San Joaquin Local He&lth District. <br /> JOB ADDRESS/LOCATION U 6. c� CENSUS TRACT <br /> 'Otaner's Name <br /> Phone —� <br /> Address _ _ � City <br /> Contractor's Name License # 1�4 Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN / RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> PUMP 'INSTALLATION PLW REPAIR{ / PUMP REPLACEMENT <br /> Others / / F <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 I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing-- <br /> Irrigation <br /> asing Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Cont"sractor. <br /> HP <br /> y/Yp/ <br /> of Pum pPUMP REPLACEMENT: State Work Done <br /> i PUMP 'ZEPATR: / / State Work Done <br /> t <br /> ,DRgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <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 .thelwell and notify them before putting the well in use. The above <br />' . information true to the best of my knowledge and belief. <br /> TITLE -tee ri <br /> SIGNED {DRAW PLOT PLAN ON REVERSE SIDE) <br />'f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> 1-11 t <br /> ADDITIONAL COMDMNTS: <br /> PHASE II GROUT� INSPECTION PHASE III FINAL INSPECZPN <br /> INSPECTION BY DATE INSPECTION BY r DATE <br /> CALL F'OR A GROUT INSPECTION PR10R TO GROUTING AND FINAL INSPECTION. <br /> u �F 5r731M <br />