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SAN JOAQUIN LOCALHEALTHDISTRICT <br /> .F 01 ICH USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-.3- 3 a) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED 'Date Issued/� <br /> (Complete In Triplicate) <br /> Application is hereby made tb 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. <br /> I <br /> JOB ADDRESS/LOCATION3,694 <br /> CENSUS TRACT <br /> Owner's Name X4 ? -�r_�i��•� �._.. _ Phone 4 6 G Gs 3 <br /> Address 3 S` 70 ; sem" City . .9T/� <br /> U � <br /> Contractor`s Name JA License # z o Phone e47-719 Ef <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION /,S( PUMP REPAIR/ / PUMP REPLACEMENT -7 <br /> Other ./ / <br /> DISTANCE.TO NEAREST: SEPTIC TANK 70 SEWER.LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation la <br /> Domestic/private Drilled Dia. of Well Casing <br /> r Domestic/public Driven Gauge of Casing f2- <br /> Irrigation Gravel Pack Depth of Grout. Seal 510' <br /> Other Rotary Type of Grout'I C01.4 - <br /> Other ti Other Information,;e <br /> f <br /> aC1 776.Are . <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP U-PAIR: / / State Work Done <br /> L _ 1 <br /> DF-RTRUCTION OF WELL: Well' Diameter __ Approximate Depth <br /> Describe Material and Procedure ' <br /> S <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 true to the best of my knowledge and belief. <br /> f TITLE _ � <br /> SIGNED . <br /> 4 <br /> (D W PLOT AN ON REVERSE SIDE) <br /> '.FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> f, APPLICATION ACCEPTED BY DATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO , PH.A.S III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION $Y DATE: a <br /> CALL TOR A -GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> M tel/ <br /> x �z� 5/731M <br />