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SAN JOAQUIN LOCAL HEALTH DISTRICT 3 <br /> FOF�rOFFICE USE.. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION JOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��—� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued a= <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or. instal1 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 Joaqui Local Health District. <br /> JOB ADDRESS/LOCATION O U 2CLOATZ-Morsus TRACT <br /> Owner' .s Name _"­1C� Phone <br /> ti CityC`' '�-- ` l <br /> Address -� { <br /> License 5 D 0 Phone d7 f <br />! Contractor's Name- = <br /> TYB OF WORK (Check): NEW ,WELL / DEEPEN '/7 RECONDITION /_� DESTRUCTION /7 <br /> N <br /> PUMP INSTALLATION /GE/P� REPAIR /� PUMP REPLACEMENT PUMP I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SE LINES 2-� PIT PRIVY <br /> F SEWAGE DIS OSAL FIEL ' c- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRI ATE DOMESTIC WELL:: PUBLIC DOMESTIC WELL . �1 <br /> 1 <br /> INTENDED USE. TYPE OF WELL � r = CONSTRUCTION SPECIFICATIONS <br /> Cable Tool o` Dia. of Well Excavation <br /> Ind stxial � <br /> ' omestic/private Drilled Dia. 6f/Well Casing 10t� <br /> Domestic/public Driven Gauge" of Casing v <br /> i Irrigation Gravel Pack Depth of Grout S 1 <br /> I Cathodic Protection otary Type of Grout <br /> Disposal ' Other Other Information - P <br /> -._. .... _--� <br /> i Geophysical Ai Surg �e Seal`Ins talled B <br /> PUMP INSTALLATION: ContractorLe <br /> Type of Pu A.P. <br /> PUMP REPLACEMENT: / / State Work Done . <br /> •PUMP:'.REPAIR: / -State Work-Done-� -t <br /> ES TRUCTION OF WELL: Well Diameter f� Approximate Depth <br /> M <br /> Describe Material and .Procedure <br /> I hereby agree to complyywith 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 /> info ation is true to the,-bes-t- my-knowled�ge�and belief. I WILL CALL FOR-A-GROUT INSPECTION <br /> PRIOR OUTING AND F E ION. C <br /> SIGNED <br /> TITLE, -uf4L/ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PIIAS <br /> i DATE Z -o2---3 <br /> APPLICATIO1 ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> PRASE II-GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 0 �3cr <br /> 'i ��,i� u �Zvu�z �ZoT�jt - <br /> E R 1426 ev. 1-74 ��G � 1-74 2M -- <br />