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��- <br /> SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> �; �.:OFA;ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> TelephoAe:. (209) 466-6781 � <br /> APPLICATION POR WELL CONSTRUCTION 'OR PUMP PERMIT Per <br /> No. 3 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> �. <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct <br /> and/or install the workliherein described. , This application is made in compliance with San Jaaqu3n <br /> County Ordinance No. 1862 and the Rules-- nd,6Regulations of the San Joaquin Local Health Dis�rict- <br /> JOB ADDRESS/LOCATION mr CENSUS TRACT 0? <br /> Phone <br /> ' s Phone <br /> Owner's Name Doo 6 <br /> .A 11 City ' <br /> Address <br /> - <br /> License <br /> Contractor's Name # ! 3 - hone1-7 <br /> Check AWELL f% DEEPEN /_% RECONDITION I / DESTRUCTION / 7 rp <br /> TYPE 'OF WORK (Check) : !NEW <br /> !f PUMP INSTALLATION / / PUMP REPAIR '/&/ PUMP REPLACEMENT /� (� <br /> Other f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER. LINES _ PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD __" CESSPOOL/SEEPAGE PIT OTHER <br /> � . <br /> INTENDEI3'_USE j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />' Industrial x _ - Cable Tool Dia. of Well Excavation <br /> t. <br /> Domestic/private. Drilled - Dia. of Well Casing <br /> i ---� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ;j Other Other Information ' <br /> PUMP INSTALLATION. Contractor � <br /> Type of Pump / H.P. <br /> PUMP REPLACEMENT: � � f / State Work Done <br /> PUMP UPAIR: State Work Done p �Gt ►"���.��'" <br /> ,DFSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 wi11 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 knowedge and-belief.. <br /> I� <br /> SIGNED ` LE <br /> cr. <br /> i IM (DRAW LOT Pv ON RE 5E SIDE) <br /> f <br /> R DEPARTMENT USE ONLY <br /> ka. <br /> Pah'SE I E <br /> APPLICATION ACCEPTED.:,LBY <br /> ADDITIONAL COMMENTS: jM P 17 INSPE <br /> PHASE IIS GROUT INSP CTION DATE <br /> INSPECTION BYAl. . DATE INSPECTION B ` <br /> �CALL�F'OR-A-GROUT-•INSPECTION PRIOR TO GROUTING AND-FINAL IN CT N. 5/73I <br /> V u IA9A ij <br />