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SAN JOAQUIN LOCAL 3?FAC71i .DISTRTCT <br /> FOh 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" I YEAR FROM DATE ISSUED , Date Issued <br /> (Complete In Triplicate) <br /> Application,is hereby ,made-to the San Joaquin ;Local health District for a permit to construct j. <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 Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's. Name e.- cXFel Phone i� !"-:;r IV <br /> Address12 -� s� City <br /> Contractor's Name ��,� f License L20��,- Phone-{dZ-176 ;6 <br /> TYPE OF WORK (Check) : NEW WELL bZ DEEPEN '/—/ RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ +� <br /> SEWAGE DISPOSAL FIELD �!gO CESSPOOL/SEEPAGE PIT OTHER W <br /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ! <br /> Industrial Cable Tool Dia. of Well Excavation Ile <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dorxestic/Public Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �. H.P. <br /> SPUMP REPLACEMENT: / / State Work Done � <br /> PUMP REPAIR: <br /> / / State Work Done _ <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth j <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 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 y kno ledge. and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE �3 <br /> ADDITIONAL COMMENT F <br /> PHAS UT INSPECTION PHAS INSPECTION i <br /> INSPECTION BY DATE 3 INSPECTION BY DATE <br /> CALL FOR A SPECTION PRIOR TO GROUTING AND FINAL INSP ff7 <br /> E H 1426 4/72 1M <br />