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3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workllherein 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 31 1 A,), T �f' � CENSUS TRACT <br /> Owner's Name A 7=S 'G c J'.�C1 <br /> j� Phone -- .- <br /> Address /0 <br /> City <br /> Contractor's Name ijl �- tl l� ' • [Jf�� ��j _ ^� License # `7 �dZ Phone <br /> TYPE OF WORK (Check): NEW WELL Z , DEEPEN /_7 RECONDITION _ DESTR <br /> _/-7 UCfiION / <br /> ? <br /> P,IUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 16 /' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> � Cable Tool Dia, of Well Excavation �Q <br /> Domestic/private Drilled ' , Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation j Gravel Pack Depth of Grout Seal. 12 <br /> -��U .._ <br /> Rotary Type of Grout [� <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done � <br /> PUMP REPAIR: /177 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply:11with 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 [he well and notify them before putting the well in use. The above <br /> informatio trup, to Fie est of my knowledge and-belief; <br /> SIGNED <br /> :TITL. ;" /�• <br /> II DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY D E - -7� <br /> ADDITIONAL COMMENTS: 1_1. - ; <br /> PHASE II GROUT INSPECTION _.�- P fFIVI INSPECTION <br /> INSPECTION BY II. DATE INSPECTION BY- DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 <br /> 7/72 1M <br />