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C� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U 1601 E. HazeltanAve. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -I-3 - <br /> THIS <br /> o. -I3 -TRIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued � .:- <br /> ► ' (Complete In Triplicate) ,�,,v c-CZE`-2eC-- CO' <br /> Application is'•hereby made',to 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 Ordinance4No'. '1862 and the 'Rules and''Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Phone <br /> Oumer's NatdeJ ' <br /> 9 <br /> Address . City <br /> Contractor <br /> ts Name �� License # w Phone . �.� .. <br /> � �, _ /V <br /> I <br /> TYPE OF WORK (Check): NEW WELL '. DEEPEN / / ¢ RECONDITION -7 DESTRUCTION <br /> PUMP INSTAL .AT ION / / PUMP REPAIR / / PUMP REPLACEMENT /? a7 <br /> Other / / W ; <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �� Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �� Z <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 /> E PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work_ Done <br /> ,DESTRUCTION 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 /> information is true to the best of. my knowledge and belief.. <br /> SIGNED <br /> TITLE Q <br /> (DRAW PLOT PLAN ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY _DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IIOUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -. INSPECTION BY �//-�. DATE 4 -7 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 <br />