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�;a, . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �L� <br /> FO.k_�OPFICE USE' 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3_ �„f <br /> THIS PERMIT EXPIRES :YEAR FROM DATE ISSUED Date Issued -(� j <br /> i - _ .. <br /> C3 3 -. (IC- Ut %�"I2 (Complete 'In Triplicate) �iJ Q2-1-- zfo---oL <br /> Application is herebyl:nade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the woj,k herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. � 62 and the Rules and Regulations of an uin Vocal Health District.' <br /> iN <br /> JOB ADDRESSfLOCATIO. C CENSUS TRACT 7 <br /> Owner's Name �� Phone <br /> Address City <br /> 0 <br /> Contractor's Name 'M License #6�2Z on <br /> TYPE OF WORK (Check) : A NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PIJME' REPLACEMENT /_ <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LIIJES PIT PRIVY <br /> SEWAGE DISPOSOT FIELD CESSPOOL/SEEPAGE PIT OTHER m <br /> I <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> Irldustrial ;I� Cable Tool Dia, of Well Excavation F � <br /> omesti.c/private. .Drilled Dia. of Well Casing r/ <br /> Domestic/public/public Driven Gauge 'of''Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Other Rotary Type of Grout <br /> I� Other Other Information <br /> •'ll' <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: / f State Work Dome - <br /> PUMP 'UPAIR: / / State Work Done <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comg`ly 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 my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT df. the we 3 and notify them before putting the w 1 in use. The above <br /> information is a to he b t of MY knowledge and .belief. ' <br /> i SIGNED i� TITLE <br /> iM. ' (DRAW LAN ON REVERSE SI 'E) <br /> ffiR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ f/r - � DATE <br /> ADDITIONAL COMMENTS-. . �� <br /> PHASE II.fGROUT_INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY li� DATE INSPECTION BY DATE,6 -2.01 <br /> ,CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 11. _''5/.731M S <br />