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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 /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 (o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> !� '- <br /> Owner's Name Phone <br /> Address 496 City <br /> Contractor's Name e Pte '_ License #MOLZIOrhone ,l <br /> li <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /_7 DESTRUCTION /-T <br /> PUMP INSTALLATION/ / PUMP REPAIR] / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _61ff SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation fill <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _4 Irrigation ..Gravel, Pack Depth of Grout Seal � <br /> Other Rotary Type of Grout f" <br /> Other Other Information :{ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 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 <br /> o�true to the best of my knowledge and belief. <br /> SIGNED �11"i -- - TITLE Olt, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ✓Kew DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHA E III/FINAL INSPECTION <br /> INSPECTION BY DATE . �_^� 2INSPECTION BY DATE ?� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1416 4/72 1M <br />