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OR OFFICE ;E: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No3 s-3 <br /> k . �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompletDate Issuedj� <br /> e In Triplicate) <br /> Application is hereby made to the -San Joaquin Local Health District fora ,permit to constru <br /> and/or install the work herein described. This application is made in compliance with San Jct <br /> o <br /> County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Local aquit <br /> q 1 Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT S Y/ <br /> Owner's Name V1 ° <br /> �� Phone 3 ' �■-! 7 <br /> Address <br /> ,P City <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check).: NEW WELL <br /> /? DEEPEN 4/; : RECONDITION DESTRUCTION /^] <br /> PUMP INSTALLATION PUMP REPAIR / / , PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: S PTIC TANKPR ' <br />. SEWER`LINES�._ PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OFf <br /> industrial �' CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Cable Tool Dia, of Well. E <br /> Dia. of" g <br /> xcavation <br /> Drilled DiWell-'Ca6in <br /> Domestic/public Driven f <br /> Irrigation Gauge of Casing <br /> Other Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout 4 � � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump ` <br /> H.P <br /> PUMP REPLACEMENT- / ( State Work Done <br /> PUMP REPAIR: / / State Work Done r <br /> ESTRUCTION OF WELL; Well Diameter , <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations-,or 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. will,. 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 /> SIGNED <br /> �. TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> ENSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE _. AINSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, DATE/— <br /> E H 1426 <br /> - ' 7/72 1M <br /> 4 <br />