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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3_ <br /> ;7 .� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date' lssued rp_l4.-�-3 <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 /> JOB ADDRESS/LOCATIONlo// ENSUS TRACT 3 <br /> Owners Name Phone <br /> Address E <br /> City (� <br /> Contractor's Name ' 0,f,4- <br /> ALE" License #A"/ <br /> Phone <br /> 7- TA <br /> 06 <br /> TYPIC OF WORK (Check); NEW WELL / / DEEPEN /% ,RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Q44 <br /> DISTANCE TON REST: SEPT TANK ; SEWER,:LIN S PIT PRIVY f <br /> SEWAGE <br /> DISPOSAL FIELD CESSPOOL/SEEPAGE PI 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 G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump PAV fij r <br /> H.P. <br /> PUMP.-REPLACEMENT:- Stafe Work Done' gl z <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter « A proximate Depth <br /> escribe Mat rial and ProcedureAJIL. <br /> I hereby .agree to complywith all aws alidl regulations of the San oaquin Local He�lalth 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 /> informationZitrue to the best of my knowledge and belief; - 'ti ,..�._* .'` <br /> SIGNED S <br /> r TITLE 4 . <br /> S,(IVAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY- <br /> PHASE <br /> NLYPHASE i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE p <br /> _ ,� �'�'�3 INSPECTION BY DATE . <br /> CALL .FOR A GROUT INSPECTION PRIOR TO GROUTING,AND FINAL INSPECTION. <br /> E H 1426 � � 7/72 1M ,�,� <br />