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b <br /> SAN JQAQUIN LOCAL HEALTH DISTRICT <br /> F01,:0 `ICE USE: 1641 E. H'azeltvn Ave-. , Stockton, Calif. 4 <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 3-�{ <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued 'r��{-Z3 <br />` (Complete In Triplicate) <br /> Application is hereby Wade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wore 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 /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address <br /> '�47i a ct " R City ' . cl <br /> M f License 4�� 7�CJ khone ' <br /> Contractor's Name ' <br /> i� <br /> TYPE OF WORK (Check): i NEW WELL I J DEEPEN/ I _RECONDITION I J DESTRUCTION J-T <br /> 'PUMP INSTALLATION / / PUREPAIR / PUMP REPLACEMENT /� <br /> MP <br /> Other <br /> w <br /> DISTANCE TO NEAREST: SEPTIC T&NK 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 <br /> Domestic/private. -- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> irrigation Craves Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PU11P INSTALLATION: Contractor <br /> Type of Pu*t - d 2 H.P. ' D <br /> PULP REPLACEMENT: m: <br /> State Work-Done <br /> PUMP VPAIR: State Work Done S'fo �'S�i1S4 Jlatl��� d 1111 <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T — Describe Material. and Procedure <br /> J� of the San Joaquin Local Health District <br /> I hereby agree to comply with all. laws and regulations q <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> ater completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> f <br /> WELL DRILLERS REPORT "o£ ':the well And notify them before putting the well in use. The above <br /> i information is true to the best of my k wled be ef. <br /> SIGNEDTLE <br /> D OT PL ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA AL PEC'TZ0 <br /> INSPECTION Bf.. �� DATE INSPECTION BY WE <br /> .CALL -FOR A GROUT-INSPECTION-PRIOR TO GROUTING AND FINAL INSP TION. <br /> W u 1A9A 11 S/7 -_ <br />