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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, S-3 L vj ' <br /> THIS PERMIT EXPIRES 1-YEAR FROM-DATE ISSUED Date Issued .5 t.: - 7 3 <br /> (Complete In Triplicate) <br /> Application is hereby made to`ithe 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 Regulations, of the San Joaquin Local Health District. { <br /> JOB ADDRESS/�OCATI^ON" CENSUS TRACT <br /> e <br /> Owner's Name Phone" <br /> Address <br /> A- , City.. <br /> Contractor's Name /�, � � License Phonefflj- <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /-7 RECONDITION DESTRUCTION /-7 _ <br /> PUMP IgSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT I I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE Off' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> Domiestic/private I)e Drilled Dia. of Well Casing <br /> Domestic/public -.I Driven Gauge of Casing H <br /> Irrigation Gravel Pack Depth of Grout Seal '7 <br /> Other # X- Rotary Type of Grout <br /> 3 <br /> `, Other Other Information _ <br /> it <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- _ <br /> / / State Work 'Done <br /> PUMP REPAIR.-- J / State Work Done <br />,PES 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 best of my knowledge and belief. <br /> SIGNED? TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID—E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - �--� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II G OUT INSPECTION ' PHASE III/FINAL INSPECTION <br /> INSPECTION BY ! DATE —iy-23 INSPECTION BY DATE r:: ,---23 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />