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4 / 1 <br /> y`/// SAN JDAQi3IN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,3-35 <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 21 <br /> (Complete <br /> In Triplicate) 61-5,1 m � <br /> APPlication is hereby made tdithe San Joaquin Health istrict for a permit to cons <br /> Cruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ A _� CENSUS TRACT S 7 <br /> Owner's Name <br /> Phone 30--Z6 A <br /> 61 <br /> Address 7 �' ��-��.��� � City } <br /> Contractor's Name Z �r License IV( <br /> Phone3 <br /> TYPE OF WORK (Check): NEW WELL / 7 DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �+ <br /> Industrial Cable Tool Dia, of Well Excavation y� <br /> Domestic/private 4 Drilled Dia. of Well Casing <br /> Domestic/public ;{ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �"" _ 1 Rotary Type_--of- Gr-out <br /> Other Information <br /> PUMP INSTALLATION: Contractor ? <br /> Type of Pump -- H.P. <br /> .P. _ <br /> PUMP REPLACEMENT: State Work Done - p <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 TITLE <br /> r' <br /> {DRAW PLOT PLAN ON'REVERSE SIDET� <br /> FOR DEPARTMENT USE ONLY"', <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS, — - --- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />.INSPECTION BY DATE 1-.INSPECTION BY ��' DATE <br /> -''.ALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> /FI 1426 7/72 1M low �' <br />