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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '0—T OrFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssufflR 3 1978 <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 Jbaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name Phone 2 <br /> Address City <br /> Contractor's Name Lam. . License I/ Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> W PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES F PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial „ .x_ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 5/,':i <br /> Domestic/public Driven Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor �f G/�p <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFgTRUCTION 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 well "construction. Within FIFTEEN. DAYS <br /> after completion of my work on a new well, I will furnish the Sart Joaquin Local Health District a t <br /> WELL DRILLERS REPORT of the well and notify thein before .putting the .well. in .use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED .. l <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE Z"^ Z.7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ,III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F 9 IATA, if /71 tar <br />