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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D s <br /> FO)z OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 �} <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- 3, 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (Complete In -Triplicate) <br /> Application is hereby made tolthe 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 /> I he Ru es d Ike Mations of the San Joaquin Local health District. <br /> It <br /> County Ordinance No. 1$62 and ^ p CENSUS TRACT <br /> JOB ADDRESS/LOCATION r <br /> I� Phone <br /> Owner's Name ,_ �� t '� <br /> _ Cf ty .r <br /> Address <br /> / icense # d�3 - Phone �� i <br /> Contractor's Na <br />! TYPE OF WORK (Check) : NEW WELL f / DEEPEN / ,/ RECONDITION %� DESTRUCTION / T <br /> PUMP :INSTA LATION / ] PUMP REPAIR jX/ PUMP REPLACEMENT ]7 <br /> Other/ / <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS.POOLfSEEPAGE PIT OTHER v <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS S <br /> i <br /> Industrial Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private t }1 Drilled , Dia. ,of .Well Casing f' <br /> Domestic/public <br /> Driven Gauge of Casing <br /> t Irrigation # Grave L l. <br /> Pack Depth of Grout Sea - " <br /> Other Rotary Type of Grout <br /> Other _ Other Information <br /> I PUMP INSTALLATION: Contractor 011 AEc- <br /> Type sof Pump �1 H.P. C) <br /> PUMP REPLACEMENT: / / `State Work Done <br /> I ,11hs <br /> PUMP REPAIR: <br /> State Work Done ��� <br /> ' _DESTRUCTION OF WELL: Well Diameters <br /> 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 workfion a new wellIwill <br /> beforefurnish <br /> puttingSan <br /> theowellninouse.cal HeThehaboverict a <br /> WELL DRILLERS REPORT of the well and notify them <br /> E information is true to the. best of my knowledge and belief. <br /> � .TITLE �--- <br /> SIGNE fie, <br /> PLOT' PLAN ON E 'FRSE SIDE <br /> j POR DEPARTMENT USE ONLY I <br /> PHASE 14 DATE b 4j- -V)_3 <br /> APPLICATION ACCEPTED BY it <br /> ADDITIONAL COMMENTS: PRA I FINAL INSPECTI <br /> PHASE II GROUT INSPECTION M INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND .FINAL INSPECt ON. , 7/72 1M <br /> E H 1426 4. P <br /> f <br />