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OR FICE USE: SAN JOAQUIN LOCAL WALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Califs <br /> Telephone: (209) 466-6781 T13 a�� Vj <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.u--p 3 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ' Date Issued <br /> Applicat <br /> (Complete In Triplicate) <br /> ion is hereby made to the San Joaquin Loral 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 /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract, <br /> s <br /> JOB� ADDRESS/LOCATION S Q Su .7S`6S`S�A,Al U Q 1) <br /> Owner's Name ..CENSUS TRACT <br /> Ir9 1l64/4/zPhone l� <br /> Address _l� �_ <br /> City 6_ 7m*A1_e H <F <br /> Contractor's Name11 A <br /> License # <br /> Z30 Phone +L 7 f 19 <br /> TYPE OF WORK (Check) : NEW W ....ly <br /> ELL• DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT/ <br /> Other 1/ % <br /> DISTANCE TO NEAREST: SEPT IC :TANK <br /> .� SEWER LINES PIT PRIVY Lo <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITG <br /> OTHER <br /> INTENDED USE TYPE OF WELL Ln <br /> CONSTRUCTION <br /> Industrial SPECIFICATIONS <br /> v Cab1e..Taol Bia. of Well Excavation � <br /> _ k Domestic/private Drilled Dia, of Well Casing E. � <br /> Domestic/public ! Driven ------ <br /> Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> Other - 3 v <br /> t Rotary t Type of Grout - 1y <br /> ' Other "�� — �} <br /> Other Information <br /> i <br /> PUMP IN Contractor , <br /> Type of Pumpa.6 <br /> H.P. L <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,PESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APPrOximateiDepth _ <br /> I hereby agree to comply with all laws and regulations of the San JoaquinLocal Health District ` <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work onla 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 best of my knowledge and belief, <br /> I <br /> SIGNED <br /> TITLE <br /> DRA LOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t DATE 6 �l <br /> , <br /> PHASE II <br /> GROINSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECT ON . <br /> DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION <br /> E H x.426 PRIOR 0 GROUTING AND FINAL INSPECTION.z_7' DATE , <br /> S <br /> 7/72 IM <br />