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/ SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> FORSFICE E: 1601 E. Hazelton- Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 (: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `�3- 15 3 <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedH.A -_�j <br /> ► (Complete In Triplicate) <br /> Application is hereby-made to-"the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereii described. This application is made in compliance with San Joaquin; <br /> the Rubes and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 3862 and <br /> 44, CENSUS TRACT <br /> JOB ADDRESS/LOCATION .S <br /> Owner's Name .0JY'' .s�.a..rr�/�d Phone <br /> AddressL IR.�~a� City <br /> Contractor t s Nam r' t r License #d ,2# hone 74 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—T PRECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /? <br /> AL <br /> Other i/ / <br /> A <br /> DISTANCE TO NEAREST: SEPTICrTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER 1 <br /> INTENDED USE TYPE_ OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool tDia. of Well Excavation �r <br /> C Domestic/private Drilled _ Dia. of;:Well Casing w.. <br /> Vl <br /> Domestic/public ' -Driven Gauge of Casing <br /> Irrigation Gravel Pack +Depth of Grout Seal <br /> Other Rotary �� Type of Grout <br /> j Other " Other- Information <br /> � <br /> PUMP INSTALLATION.- Contractor - <br /> H.P. <br /> Type of Pump <br /> t <br /> PUMP REPLACEMENT- <br /> PUMP REPAIR: Gate Work Done R <br /> : / State Work Dane443 <br /> "? e L � /•� ��� dt� j <br /> -DESTRUCTION OF WELL: Wellr'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 /> ll construction. Within FIFTEEN DAYS <br /> and the State of Californialpertaining to or regulating we <br /> : After completion of my. workon a new well, .I will furnish the SanJoaquin 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 knowle ge belief. <br /> SIGNED � TLE <br /> Q r <br /> LOT PLAN ON RE SE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> / 1 <br /> PHASE IDATE 3 <br /> APPLICATION ACCEPTED BY �r <br /> ADDITIONAL COMMENTS: <br /> PHASE II � S CTI PHASE III FINAL INSPECTION <br /> ILL <br /> ' INSPECTION BY (;� I ATE INSPECTION BY DATE �- <br /> 4 CALL FOR A GROUT tNSPECTION PRIOR TO GROUTING AND FINAL IN ION. 7/72 1M <br /> E H 1426 <br />