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t� <br /> 0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �3_S�4W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/2.-_/,5-_ ;�-3 <br /> (Complete In Triplicate) <br /> Application is hereby made lto' -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. 1862'4nd• the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3L6L, -- U -�j'-', CENSUS 'TRACT <br /> �. <br /> me Owner t s Na -- �� ,, .%--= EL - - - Phonee� <br /> -- - <br /> z---7 �� <br /> Address � �- � U Af- S Ci t;>� <br /> Contractor's Name t4 Licensep1,0 Phone 6 <br /> TYPE OF WORK..(Check) : NEW WELL / DEEPEN /-7 RECONDITION /7 DESTRUCTION /-7 - <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> Y` <br /> X DISTANCE TO NEAREST: SEPTIC TANK S (j R L;NES ��--PIT PRIVY <br /> SEWAGE DISPOSAL FIELD < fi CESSPQOL/SEEPAGE PIT /cOTHER <br /> INTENDED-USE =�,, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation lei <br /> �'�amestic/private Drilled Dia, of Well Casing ZE <br /> ',-Domestic/public Driven Gauge of Casing 4 - <br /> Irri ation Gravel .Pack,, De th_,of Grout S <br /> g P, '�l� ct`] �zr6z <br /> G Other ' otary • Type of Grout <br /> r' Other Other Information - " <br /> PUMP INSTALLATION . Contractor ,- <br /> Type of Pixdp <br /> c S <br /> PUMP REPLACEMENT: / / Sfate Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,RESTRUCTION 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 well'and notify them before putting the well in use. The above <br /> infortion is true to th+ --be of my knowledge and belief. <br /> TITLE <br /> SIGNED ` C 0` 1 <br /> f =_ f - (DRAW PLOT PLAN ON REVERSE SIDE <br /> A FOR DEPARTMENT USE ONLY <br /> APPLICA IT0^ ACCEPTED BY DATEZ(2 <br /> ADDITIONAL--COMMENTS: & 5e <br /> PHASE TI GROUT INSPECTION 'PHASE III F AL INS CTION <br /> INSPECTION BY ---f DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 W` �7/72 1M.- - <br />