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3 �+ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE S�—x 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) , -4/25 <br /> Application is hereby made to the San Joaquin Local Health District for a permiit 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 Ru.les,,,and,rRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONV/o/9_; CENSUS TRACT 01-3-2z0-3I <br /> -- <br /> Owner's Name <br /> Phone _g<0_ p 7 <br /> Address /a?D City _ <br /> Contractor's Name ` License G# �8 S5 Phone <br /> 36 9-S/ to <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /% RECONDITION /_7 DESTRUCTION /-7 . <br /> PUMP INSTALLATION / / PUMP REPAIR LN PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool+*' Dia. of Well Excavation O <br /> Domestic/private Drilled 6,a. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ <br /> Other Other Information Ak <br /> PUMP INSTALLATION: Contractor <br /> tY Type of-Pump H.P. ci_h` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done (� <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> gs <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 /> 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 /> information is true to..the best lof',my. knowledge and belief. <br /> t. . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 13 <br /> ADDITIONAL COMMENTS: <br /> _PHASE II GROUT_INSPECTIONPHASE-III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. .�.� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM r�} <br />