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SAN JOA:QUIN LOCAL HEALTH DISTRICT <br /> IOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3 y 90 <br /> ?3_s-�� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -,Z,L -,73 <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/LOCATION �I15ya <br /> CENSUS TRACT I <br /> Owner's Name �9 ;,4 Phone <br /> Address Zze, 2� City / <br /> Contractor's Name � License #,,I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN j / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION K PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TYUK SEWER LINES PIT PRIVY * ' <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER ,II <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 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 Z'v <br /> PUMP INSTALLATION: Contractor ' P`. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DF�TRUCTION 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL ERS REPORT of the well and notify them before putting the well in use. The above <br /> inf rmatJon 's t e o the best of my knowledge and belief. <br /> 04 <br /> SIGNED TITRE !% -� <br /> (DRAW PLOT PLAN ON REVERSE SIDT) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .r DATE 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �/0 -.Cf- ,j INSPECTION BY DATE jb -73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />