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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone:- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7-J-76 <br /> (Complete In Triplicate) <br /> Application' is hereby made to the San Joaquin Focal Health Distract for a permit to construct <br /> and'/or install the work herein described. - This application is made in comp1 ance with San Joaquin! <br /> County Ordinance No. 1862 and .the Rules and Regulations of the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATI01 <br /> ON14& CENSUS TRACT - <br /> 5A <br /> Owner's Name Phone <br /> Address City' ' <br /> zi <br /> Contractor's-Name LicensePhon <br /> TYPE OF WORK (Check): -NEW WELL /Z DEEPEN '/-7 RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTLATION I PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA,V SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private,, � Z,-Drilled Dia. of .Well Casing 4Q <br /> Dom6estic/public Driven Gauge o£�Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Ik Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> ,. Type of Pump H.P. <br />} PUMP REPLACEMENT: State Work Done <br /> PUMP VPAik: /% State Work Done <br /> ,DF-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r 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 Joaquiri Local Health District a <br /> WELL DRILLERS REPORT a€ .the well and notify them before putting the well in use. The abov <br /> information is true to the best of my knowledge and belief. <br /> SIGNED � ? ,P/1 _ _ TITLE <br /> .i <br /> (DRAW PLOT PLAN ON REVERSE SID -- <br /> Ate_ FOR DEPARTMENT USE ONLY <br /> PHASE I ���� <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMN,ENTS: . <br /> PI E I OUT. INSPECTION PHASE III/FINAL NSPECTION " <br /> INSPECTION BY TE `'~ INSPECTION BY DATE <br /> ­ CALL FOR-A GROUT INSPECTION-PRIOR -TO-GROUTING AND FINAL INSPECTION. / <br /> R H L126 <br /> 4 , 5 731M <br />