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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 , /, 7L_ <br /> (Complete In Triplicate) <br /> Application is hereby made to 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 kealth District. <br /> JOB ADDRESS/LOCATION r S J/�1 CENSUS TRACT <br /> Owner's Name ��Ir'_7L C ! }- Phone <br /> Address <br /> City <br /> Contractor's Name SAC L Ic License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTALLATION /4�_7 <br /> PUMP REPAIR / / PUMP REPLACEMENT /`7 <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -� <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> I--- Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _N <br /> Other Other Information 6` <br /> r-- <br /> PUMP INSTALLATION: Contractor go <br /> Type of Pump �f Cv ZZ 1rU H.P. Z <br /> fp`+m,-9 A, A46WOV" Fo-'e0l + D.V6� Lv&5-Lr12 /.-vSIAw[CN/ <br /> PUMP REPLACEMENT: / / State Work Done !/v7-0. -�V&y D,�/G�• _— <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complywith 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 e o t bes of y nn edge and belief. <br /> SIGNED TITLE OWNF-/l- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEI FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 7/72 1M <br />