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OA UIN ,LOCAL HEALTH DISTRICT <br /> SAN J Q � <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,3- <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED }Date Issued —7-22.,7-3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Jaaquin Local Health District for a permit to construct <br /> and/or install the work here- described. is made in compliance with San Joaquin <br /> i " This application <br /> r County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> I� a CENSUS TRACT <br /> JOB ADDRESS/LOCATION. 7 L <br /> I ; Phone <br /> Owner's Name, 7 (` <br /> City <br /> Acddress. <br /> License # ���jPhone '1-7� , <br /> I <br /> Contractor's .Name <br /> I� RK (Check) .' NEW WELL-/—/ -.DEEPEN ' / RECONDITION / / DESTRUCTION -7 <br /> RECONDITION <br /> TYPE OF WO <br /> PUMP INSTALLATION "J�! PUMP REPAIR '/ / PUMP REPLACEMENT / <br /> s <br /> other -/ <br /> TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> DISTANCECESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD _ <br /> f � INTENDED USE TYPE. OF' WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 8` <br /> t � Domestic/private Drilled Dia. of Well Casing <br /> iM Domestic/public Driven Gauge of Casing <br /> � Irrigation Gravel Pack Depth of Grout Seal <br /> i� Other Rotary Type of Grout <br /> IM Other — Other information <br /> 01 <br /> PUMP INSTALLATION: Contractor C <br /> F H.P. ' / z <br /> Type of Pump <br /> I <br /> PM- REPLACEMENT: State Work Done <br /> PUMP `tEPAIR: State Work Done <br /> Approximate Depth <br /> t DF. TRUCTION OF WELL:' Well Diameter <br /> Describe Material and Procedure <br /> regulations of the San Joaquin Local Health District <br /> I hereby agree to comply with. all laws and reg . <br /> j, egulating well and the State of California pertaining to or r ''construction. Within FIFTEEN DAYS <br /> afl` The above <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> i [,CELL DRILIt. RS REPORT of .the well and notify them before putting the well in use. <br /> iriformatioa is true :.to _the best of my knowlede a belief. <br /> j ITLE <br /> S GN dam! • <br /> ~(D PL T .PLAN ON ER5E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> F P II3ASE T DATE <br /> APPLICATION ACCEPTED $Y <br /> ADDITIONAL COMMENTS: PPHA IO IN5PEC <br /> 11 PP4ASE II GROUT INSPECTION INSPECTION DINSPECTION BY DATEf-CALL FOR-A GROUTIINSPECTION PRIOR TO GROUTING AND FINAL IN5/731M <br /> V tit 1499 <br />