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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` FOR OFF%CE USE: V/ 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> TMS .PERMIT EXPIRES 1- YEAR FROM DATE ISSUER <br /> 'Date Issued <br /> I (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. 3862 Anc the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 434S Road CENSUS TRACT <br /> Owner's Name. ' Ra us' Real Estate& Ins., Inc. 823-3148 <br /> Phone <br /> Address <br /> City Mantel <br /> Contractor's Name J <br /> License 4�.��'C�G� � Phone <br /> TYPE OF WORK (Check): NEW WELL / - DEEPEN /? RECONDITION /? DESTRUCTION /-7 <br /> PUMP INAL <br /> STLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other 4% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK �y�_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS " l <br /> _ Industrial 1 Cable Tool Dia. of Well Excavation <br /> rJ Domestic/private i Drilled <br /> Dia. of Well Casing ' <br /> Domestic/public i Driven Gauge of Casing m <br /> Irrigation J Gravel Pack Depth of Grout Seal m, <br /> Other Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /-7 SIate Work Done <br /> ESTRUCTION OF WELL: Well 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 s <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 4n use. The above <br /> information is true to the best of my knowledge and belief. r' <br /> SIGNED (� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I m FOR DEPARTMENT USE ONLY �y <br /> APPLICATION ACCEPTED BY DATE IS <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />