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SAN JOAQUIN LOCAL HEALTH DISTRICT *_C5 01 i <br /> FOR OFI+ICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <br /> (Complete In Triplicate) <br /> Application is hereby made t� 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 l CENSUS TRACT -- <br /> Owner's Name Phone <br /> C ! E <br /> Address �,- / C� ! ('1r o� City <br /> L <br /> E NINGS $ROS it IN License �� Phone <br /> Contractor's Name _ <br /> 2500 W. .R1LE-__R0AQ « __ �- <br /> MODESTO, CALIF, RISE 1632 <br /> TYPE OF WORK (Check) : NEW WELL DEEPE� j^T RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT <br /> E Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t. <br /> ' Industrial Cable Tool Dia. of Well Excavation <br /> e� Domestic/private t__ Drilled Dia, of Well Casing <br /> Domestic/pubi'ic Driven Gauge of Casing OAA <br /> ' Irrigation Gravel Pack Depth of Grout Seal &.- <br /> Other 4--Rotary Type of Grout iii. 1,-_.-Xe- <br /> Other <br /> .eOther Other Information <br /> 4 <br /> r <br /> PUMP INSTALLATION: Contrlactor <br /> Type of Pump H.P. <br /> ` PUMP REPLACEMENT: State Work Done <br /> PUMP-.REPAIR: -/ / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <br /> F 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 of my knowledge and belief. <br /> SIGNED TITLE <br /> 40 <br /> OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> , ADDITIONAL COMMENTS: <br /> PHASE II f.ROUTIINSPECTION hNa INSPEC N <br /> INSPECTION BY --1-DATE -�? - INSPE DATE " �- <br /> 73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 G13 <br />