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SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOE. OFFICE- USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> I Telephone: (209) 466--6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 S��J <br /> THIS PERMIT EXPIRES .. YEAR FROM DATE ISSUED Date Issued j—�U=-77 <br /> (Complete In Triplicate) <br /> Application is hereby ode t the San Joaquin Local Health District for a permit to construct <br /> and/oz. install the work herein described. ' This application is made in compliance with Saxe Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 11.e�?1.th District. <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> F <br /> 'Owner's Name <br /> er <br /> City - i <br /> Address " <br /> License Phonf .. <br /> Contractor's Name <br /> TYPE OF WORK (Check) :;V NEW WELL DEEPEN/_I RECONDITION / I DESTRUCTION <br /> PUMP INSTALLATION PL't`� REPAIR / PUMP REPLACEMENT 1_7 <br /> Other../ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPEOF ,WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation v <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation <br /> Gravel. Pack Depth of Grout Seal � <br /> OtherRotary Type of Grout _ <br /> Other _ Other Information <br /> n <br /> PUMP INSTALLATION: Contractor H.P. <br /> Typel of Pump <br /> 4 <br /> PUMP REPLACEMENT: I I State Work Done <br /> PiTMPY'ZEP <br /> iE - -� =-� { S'ta'te=Work Done <br /> _ ALR: I" <br /> pt <br /> S"Well. Diameter rx xamate fie _` <br /> ;� ,Dk' TRUCTION O.F�nT . <br /> Describe Material and Procedur <br /> s` <br /> I hereby agree to comply with all laws and regulations o the San ,Toaquin Lo al Health Distritt <br /> and the State of California pertaining to or regulating, ell coristtuction-.—Withiii'F1F='TEEN DAYS <br /> k' after completion of my work on a new well, I will furnis Ythe'San Joaquin L Co -1-Health-Dkstrict a <br /> WELL DRILLERS REPORT of the well and notify them before offing the well in us T above� <br /> information is true to the best of my knowledge and b f. � '� rye <br /> i TITLE I- 7�4'77 <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE­SIDE} <br /> FOR DEPARTMENT USE ONLY f 3 <br /> k PliASE I DATE �� J <br /> 'j APPLICATION ACCEPTED .BY <br /> ' ADDITIONAL COMMENTS: PHASE I/FI, INSPECTION <br /> PHASE I GROU INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY �INS;ECTION <br /> TE I <br /> CALL FOR A G -PRIOR TO .GROUTING AND FINAL INSPECTION. <br /> .. �� r- T G�v7 — //6 Gr w«v /731t� <br />