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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOR OFFICE USE: <br /> Stockton Calif . <br /> 1501 E. Hazelton Ave. , <br /> Telephone: (209) 466=6781-t <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 3 Date Issued <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED 3 <br /> r v• , (Complete In Triplicate) , <br /> ct <br /> Application is hereby made to, de cribed. Tnhisoapplication iscal Health tmade inrict rcompliance.a permit twith nSareuJoaquin <br /> and/or install the work herein described. <br /> County-Ordinance No. 1862 andl h Ru e + and <br /> Reg Mons sof the San Joaquin Local Health District. <br /> £ <br /> .. 7 ► CENSUS TRACT <br /> JOB ADDRESS/LOCATION .bi <br /> Phone t <br /> owner's Nature 4 <br /> City <br /> Address <br /> 254 License # �YS Phone <br /> Contractor`s Name c,5 - <br /> E <br /> PEN i� / ./ RECONDITION /7 DESTRUCTION I-T <br /> TYPE OF WORK (Check): NEW WE // <br /> LZ, DEEPUMP 'INSTALLATION I I PUMP REPAIR IXI PUMP REPLACEMENT I� <br /> Other; /—/ <br /> DISTANCE TO NEAREST: SEPTIC! TANK _ SEWER LINESr_ _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD: CESSPOOL/SEEPAGE PIT OTHER — <br /> 4 <br /> INTENDED _USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial — / Cable Tool Dia, of Well Excavation <br /> —Dong <br /> mestic/private Drilled Dia. of We11, C.-, . <br /> Domestic/public Driven M 'Gauge of Casing <br /> Irrigation . • Gravel Pack Depth of Grout- Seal _ <br /> Other Rotary Type of Grout <br /> ` ------ Other, Other Information <br /> PUMP INSTALLATION" Contractor ' <br /> � H.P. <br /> Type of Pump <br /> 1 r i <br /> PUMP REPLACEMENT: / / - State Work Done - <br /> PUMP <br /> one _PUMP REPAIR: ; <br /> State Work-Done w <br /> nESTRUCTION OF WELL: <br /> Well Diameter Approximate Depthr <br /> . Describe Material and Procedure <br /> Of � <br /> t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> lwll <br /> EEN DAYS <br /> and the State -of California pertaining to <br /> or regu <br /> willfurn3gshethe� t <br /> SanJoaquin• Within Local Health a <br /> after completion of my work on a new well, <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 /> SIGNED f "' ` PLO FLAN ON RkR SIDE <br /> DEPARTMENT USE ONLY <br /> � PHASE I ' <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t� PHASE III FINAL INSPECT N <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY ? DATE <br /> CALL FOR A -GROUT.INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 IM'' <br /> E H 1426 <br />