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It ` .. <br /> SAN JOAQUIN L©`6AI. HEALTH DISTRICT <br /> MICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone• (209) 466--6781 <br /> ' do 3� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 '- <br /> THIS PERMIT EXPIRES 1 YEAR-FROM_ DATE ISSUED Date Issued ­ -3-23 <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 herein described. This application is made in compliance wilth San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Iled1th District. <br /> i JOB ADDRESS/LOCATION _- /F NAt& CENSUS TRACT , <br /> Owner's Name f'YL O/(/ Phone <br /> Address 4 `7 — 1A City <br /> Contractor's NameY.4 <br /> TA A m eg. G o License # 27 zy e` Phone-'dr 77.1'tS,, <br /> I 1 <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN /r/ RECONDITION /_7 DESTRUCTION /`7 <br />' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT �J? <br /> 0 then <br /> DISTANCE TO NEAREST: SEPTIC TANK 7,0 ' 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 /o " <br /> Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge.of Casing . f <br /> Irrigation Gravel Pack Depth of Grout Seal e� 4--1 � <br /> Other } - x Rotary Type of Grout ^"- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �c� _ <br /> Type -of Pwmp. H P. <br /> PUMP REPLACEMENT: / Jj State Work Done . <br /> f PUMP UPAIR: / / State Work Done <br /> DFITRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure 3 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the-"�tate of Califernialpertaining to or regulating well '•construction. Within FIFTEEN DAYS <br /> after completion of my workjon 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 /> dt1t,,0 TITLE <br /> 't r DRAW PLO PLAN 13N REVERSE SIDE <br /> ' FO DEPARTMENT USE ONLY • � <br /> PHASE.1 R <br /> APPLICATION ACCEPTED .B DATE <br /> ADDITIONAL COUNTS: <br /> PHASE II GROUT INSPECTION l PHASE I ' ./FINAL INSPECTION <br /> INSPECTION BY DATE -"?3 INSPECTION BY DATE S-�1 <br /> g <br /> CALL FOR A OUT INSPECTION PRIOR TO GROUTINGkAND FINAL INSPET,10N. <br /> - E H 1 -2.6 5/733M G�- <br />