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( SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> c I� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 it <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District/for a permit to construct <br /> and/or in the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance`No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> da <br /> JOB ADDRESS/LOCATION -3/51& Y r1 CENSUS TRACT <br /> Owner's Name <br /> —(iv �.l ROS - —... Phone3 7 <br /> Address City J <br /> -Contractor's—Name _ �" t4 <br /> License�� Phone <br /> �I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /_/ DESTRUCTION ,/. <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT IT7 <br /> Other i�. <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES ' •. , PIT PRIVY <br /> SEWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE — PRIVATE DOMESTIC WELL � "'"" "PUBLIC DOMESTIC IIWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation IM <br /> Domestic/private Drilled Dia, of Well Casing IM <br /> Domestic/public; Driven Gauge of Casing Ip <br /> Irrigation Gravel Pack Depth of Grout Seal IMS <br /> Cathodic Protection Rotary Type of Grout IM <br /> Disposal '* -Other Other Information ' IM <br /> Geophysical -Surface Seal._Installed By: Q. <br /> PUMP INSTALLATION: Contractor <br /> OType of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:- `%%'stata Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> De tribe Material and Procedure -A 1N5� <br /> W <br /> i., <br /> I hereby agree—to-,ic'omply with alI-laws and--regi -s .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, <br /> J11 The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION' <br /> PRIOR TO GROUTINQ FINAL <br /> SIGNED . . ;/ TITLE 6 w Al <br /> DRAW. PLOT PLAN 'ON RE EES E SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE IC AY <br /> APPLICATION ACCEPTED BY DATE 111-/.1'?G• <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P IV/FINAL INSPECTION_ <br /> INSPECTION BY DATE INSPECTION BY DATE 1 /77 <br /> E H 1426 Rev. 1-74 3/76 <br />