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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466--6781 �� i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 io <br /> PHIS 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 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 JOB ADDRESS/LOCATION 3 3 5 �D eIW5 <br /> CENSUS TRACT <br /> Owner 1 s Name Phone <br /> iE Address 4T } City <br /> Contractor's Name f Ira-, C_ 6 Licen; y Iql-1 � Phone�(��v� // i <br /> a . <br /> i <br /> s, ray I <br /> i TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION 1-7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY g <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT SD OTHER 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 41 <br /> f Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing —kms Z <br /> V Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal &--O <br /> Other _ j/' Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION, Contractor <br /> Type of Pump Gj H.P. 14 J� � <br /> PUMP REPLACEMENT: / / State Worts Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of nay 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 /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR 'DEPARTMENT USE ONLY <br /> i PHASE I <br /> iAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> IGRO� <br /> E II GROUT INSPECTI N PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 5-111 <br /> k CALL FOR AINSPECTION PRI R. TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 7/72 1M <br />