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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P.0 TICE USE, : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No.�3-S` Q P:� . - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued --7 3 <br /> t (Complete In Triplicate) <br /> Application is hereby made tofthe 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 andithe Ruses and Regulations of the San Joaquin Local Health Disgrict. <br /> JOB ADDRESS/LOCATION: r CENSUS TRACT . <br /> Owner's Name 14 a t-0 Phone �- <br /> - --- - <br /> Address _ 0 !�� la - - City' ' <br /> Contractor's Name cu License 4 /�U 2y�Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ I RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PbW REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial " Cable Tool. Dia, of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ! Gravel Pack. Depth of Grout Seal <br /> Other t Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor N <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT ', { / State Work Done <br /> PUMP *REPAIR: State Work Done e. <br /> U <br /> ;DFgTRUCTION OF WELL: Well Diameter Approximate Depth n <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 wall furnish the 'San Joaquin Local. Health District a h <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 andbelief. <br /> SIGNED -- <br /> (DRAW PL AN N REVERSE E) <br /> FOR VEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL CO101ENTS: <br /> PHASE II 9ROUT INSPECTION PHA III/ INAL INSPECTIO <br /> . INSPECTION BY DATE INSPECTION BY DATE l/ 3 <br /> CALL FOR A-GROUT-INSPECTION PRIOR TO: GROUTING .AND FINAL INSPEC ON. <br /> E H 1426 _ 5/731M <br />