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FICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' CS 1601 E. . Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 - 3tz v�n <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r Date Issued 6- 3 <br /> Triplicate) <br /> Application is hereby made to the San -Joaquin Local HealthDistrict for a ' ermi <br /> and/or install the work herein described. This application is made in compliancetwith nSanuJoaquir <br /> County Ordinance No. 1862 add the Rules and Regulations of the San.Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION - <br /> F CENSUS TRACT <br /> Owner's Name ry ti . <br /> ` Phone-14 <br /> Address J9r <br /> Contractor's Name , a <br /> City c3- u <br /> tTM _ _ - ,,License 23 ?3 Phone. A . <br /> � - <br /> 4 r <br /> 4 <br /> F' TYPE OF WORK-(Check),: - NEW WELL f DEEPEN-, RECONDITION"'/ DESTRUCTION-/7-+__ i <br /> PUMP INSTALLATION Nr_PUMP REPAIR / / PUMP REPLACEMENT / , <br /> Other / / - 1 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES r <br /> SEWAGE'DISPOSAL FIELD PIT PRIVY ` <br /> y b CESSPOOL/SEEPAGE PTT OTHER <br /> -INTENDED USE <br /> TYPE'OF'WELL� ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool <br /> Domestic/private - Dia. of Well ExcavationoZ r� <br /> Drilled Dia. of Well Casingl f �f <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br />` - Gravel Pack Depth of Grout Sea <br /> Other Rotary <br /> --,Type of Grout <br /> Other Other Information 1 r <br /> PUMP INSTALLATION: f - <br /> Contractor'' <br /> Type of Pump - <br /> H.P4 <br /> PUMP REPLACEMENT " tate work Il!n <br /> oe <br /> PUMP REPAIR: / / State Work Done <br /> ESTftUCTI0IV OF WELL: yWell'Diameter <br /> Describe Material and Procedure Approximate Depth _ <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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.information is true to the hest of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> F <br /> PHASE II GROUT INSPECTI <br /> INSPECTION BY PHASE II /FINAL INSPECTION <br /> DATE -7X 7 7 INSPECTION BY DATE -/s= 73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> H 1426 <br /> E <br /> - �--� 7172 1M � <br />