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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �, flIFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3s 2G� <br /> THIS;PERMIT EXPIRES l YEAR:FROM DATE ISSUED Date Issued 7:-1 73 <br /> n ; xr <br /> 1 , (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health District fora <br /> and/oar install the work herein described. ' This application is made in compliance with San Joaquin <br /> County O i anc No'. F1862 and the Rules and Regulations of the San Joaquin Local,lle l. th District. <br /> 47 I CENSU <br /> ON RAr <br /> S TRACT S y <br /> JOB ADDRESS/ CA c, <br /> Phone �� 1 <br /> Owner's Name <br /> City ' <br /> Address <br /> l Z�,3 Phone�y�'/13 � <br /> .� License_ � <br /> Contractor Ps <br /> �... .= <br /> TYPE OF WORK- (Check) : NEW WELL / DEEPEN '/ / RECONDITIONSTRUCTION_/ g�EREPLACEMENT /_T <br /> PUMPiINSTALLATION / PUMP REPAIR / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAIJK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> STRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL CON � <br /> L�Cable Tool Dia.. of Well. Excavation / <br /> Industrial <br /> gestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ' Gravel Pack Depth of Grout <br /> eal Ca <br /> t S <br /> Other - � Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: f/j State Work Done <br /> PUMP TtEPAIR: / /#i State Work Done ._.� . <br /> Approximate Depth <br /> 1]F�TRUCTION OF. WELL: Well Diameter <br /> Describe Material and Procedure <br /> 1 <br /> E I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ction. Within FIFTEEN DAYS <br /> and the State..of California pertaining to or regulating well"constru <br /> after completion of my work on a new well, I will .furnish the San Joaquin Local Health District <br /> ify them before putting the well in use. The above <br /> WELL DRILLERS REPORT of the well and not <br /> information is true to the best of my knowledge and belief. <br /> ( a TITLE <br /> SIGNED � <br /> (DRAW PLOT PLAN ON REVERSE SIDS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE DATE ����•� <br /> PZ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE JIJAKINAL INSPECTION <br /> r PHASE II G120UT INSPECTION INSPECTION BY � DATE � •/-7�'3 . <br /> INSPECTION BY: DATE. '7 v <br /> CALL- FOR A :GROUT -INSPECTION PRIOR TO GROUTING AND-FINAL -INSPECTION. <br /> 5/731.M _. <br />