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- -I <br /> ' -- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave'. : Stockton, Calif. � <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77. q11 ° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued LTi it <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. 1862 and ,the Rules and Regulations of the San Joaquin Local Health District.. F <br /> JOB ADDRESS/LOCATION cry CENSUS TRACT <br /> Owner's -Name Z—/ /�'. Phone �� <br /> Address. O It Dr F/� r�G City <br /> Contractor's Name4W Zl _ //3 License I�,�Zf�.ZOJ Phone ' <br /> I <br /> TYPE OF WORK (Check): NEW WELL /Z?�DEEPEN '/_7 xZECONDITION /__7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial [/Cable Tool Dia. of Well Excavation ' <br /> 1,----Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing � . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Informations-'- ' <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done { <br /> I <br /> .)ESTRUCTION 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_ 'r <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 /> SIGNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / r <br /> APPLICATION ACCEPTED BY DATE L_ <br /> ADDITIONAL COMMENTS: r <br /> PHAS' INSPECTION P INSPECTION <br /> INSPECTION BY f ATE INSPECTIONBY DATE <br /> CALL FORN EC ON PRIOR TO GROUTING AND FINAL I P N: <br /> I E H 1426 . 4/72 IM <br />