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__ JOAQUIN LOCAL HEALTH DISTRIC <br /> i r0£. Ol'LiCE USE: 1603M. Hazelton Ave. , Stockton, Cali'f•. <br /> �_- Telephone: (209) 466-6781 q <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. 0 3` FS3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I12 73 <br /> (Complete In Triplicate)- <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <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 Yi Sit) <br /> OSI Lll/ Cf N��� • "'CENSUS TRACT ` <br /> - <br /> Owner's Name j � � s� R p S< Phone ?�S-_ oc;-C1 7 2-- <br /> ?U <br /> Address S j� Z City �Fv <br /> Contractor's Name ,. ' £'. U 142 License #1)0115z Phone,�25-�//0 <br /> TYPE OF WORK (Check) : NEW WELL- / -/ DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> POMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 .1 ,3 tL" <br /> PUMP REPLACEMENT: / / State Work bone <br /> PUMP 19� State Work Done <br /> DFv,TRUCTION 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 will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we 1 and. •notify them before putting the well in use. The above q r� <br /> information is true to th be of my nowledge- and'belief. - Fct C,/� 3�01 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PiiASE I <br /> APPLICATION ACCEPTED BX <br /> DATE <br /> ADDITIONAL C011MENTS:' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 u i A94 7�iwt <br />