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SAN JOAQUIN 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 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -&1j07-), <br /> (Complete In Triplicate) <br /> Application is :hereby made::to the San.,Jbaquin 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 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> uw <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> d <br /> Owner.'s Name / Z.� �.. Phone <br /> Address I City <br /> Contractor's Name' LD 0 -9ti License # 3 y Phone <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN -/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP. INSTALLATION A;7 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 /> 1 <br /> INTENDED USE ` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; � Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing 14 �1 — {� <br /> F Domestic/public � Driven Gauge of Casing 1� <br /> Irrigation Gravel Pack Depth of Grout Seal. � 1 <br /> Other Rotary Type of Grout <br /> Other Other Information - <br /> PUMP INSTALLATION: Contractor <br /> Type3 of Pump H.P. <br /> 3 PUMP-REPLACEMENT: /T State Work Dane !l.C�cit3 r <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedures t !` <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 Ion a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of theiwell 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 4Z�L�alt_r�� <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/ %v <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT, INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE yy f- INSPECTION BY DATE 19-4- <br /> CALL <br /> 9•4-CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />