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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O ICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3_�!1 <br /> (f THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Application, is ;hereby made;to' the .Saiz 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 Joaquir <br /> County Ordinance;,No. 1862.and'the Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION _j CENS S�TRACT �^ <br /> jOwner's Name w r Phone <br /> Address City Ci —l3 nrr <br /> Contractor's. Name �,� License #a. 63 Phone <br /> TYPE OF WORK (Check):—_`NEW WELL / ~ DEEPEN /7 RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION /Z7rVUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER L ES PIT PRIVY �� <br /> SEWAGE DISPOSAL FIELD �=O fCESSP00L/SEEPAGE PIT O "THER <br /> INTENDED USE TYPE OF WELL y CONSTRUCTION SPECIFICATIONS <br /> I dustrialCable Tool Dia. of Well Excavation Q <br /> Domestic/private Drilled Dia., of WE1lr Casing ��• <br /> Domestic/public Driven Gauge -of Casing <br /> R. Irrigation Gravel Pack Depth of Grout Seal <br /> i Otherotary Type of Grout _ --' /L,_1 <br /> _aK <br /> `w Other I Other Information <br /> PUMP `INSTALLATION: Contractor <br /> Type of Pump P. --! <br /> PUMP REPLACEMENT: / / State Work Done <br /> e _ <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 /> , afterrcompletion 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 /> inform"tionfis true to the b m nowledge and belief. <br /> SIGNED,. i TITLE <br /> W PLOT FLAN ON REVERSE SIDE -- <br /> t FOR DEPARTMENT USE ONLY <br /> PHA I <br /> APPLICATI1DN EFT BY BATE <br /> ADDITIONAL COMME <br /> P ROUT INSPECTION PnggIftffa INSPECTION <br /> INSPECTIONDATE INSPECTIO X <br /> f � <br /> CALL FOR;A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> i , <br />