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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi+rOFFICE 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 <br /> F j (Complete In Triplicate) <br /> Application is hereby madefto 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 Ordinance No. 1862 and the Rules and Ruylation f th San Joagpin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> M Address ! :. �J <br /> City ��-✓•�-�t a <br /> Contractor's Name <br /> ...HAnT1i3g Bros_ I7ri 1 l 1 g CQ+ _ Tnc. License # p9ngj phone 522-1023 <br /> PIN W, Rpmhjf� BA <br /> TYPE OF WORK (Check): NEW WELL /o DEEPEN /7 RECONDITION /_7 DESTRUCTION /-T <br /> PUMPIINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17Other <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> =�_ <br /> Domestic/private ► &----Drilled Dia. of -Well Casing • <br /> Domestic/public 1 Driven Gauge of Casing p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -�otary Type of Grout' c <br /> Disposal, A Other — _ <br /> Other Information <br /> Geophysical I ��` 'Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> # Type ,of Pump H.P. <br /> PUMP REPLACEMENT: E7 State Work Done <br /> S <br /> PUMP 'REPAIR: /-' State Work Done <br /> ES-'TRUCTION 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-beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED Bros, Drilling Co. Inco See* <br /> f b TITLE <br /> !� (DRAV PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I -- <br /> APPLICATION ACCEPTED BY .� P DATE -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 11�►S_` <br /> E H 1426 . Rev. 1-74 <br /> 1-74 9M <br />