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�4a% <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 'ICE USE: 1601 E. Hazelton Ave. , Stockton, Cal-if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -�-3 —� �"'a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L- 3 <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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION [ Li", G' L Q CENSUS TRACT <br /> Owner's Name O f_ / IV h Phone <br /> Address U3 City C � <br /> Contractor's Name /, '/ - - License # /94rar. Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / o�-��-401 <br /> ,�y_-s�/��� _...._.. <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X_ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 0 ,, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor ,, z6S7Ca <br /> G C <br /> Type of Pump H.F. �a <br /> 44 <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP REPAIR: /-7 State Work Done <br /> E_S_TR_UCTION 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 tTITLE <br /> ( PLO AN ON REVERSE SIDE <br /> _.._,_.FOR DEPARTMENT USE ONLY -- <br /> PHASE I / <br /> APPLICATION ACCEPTED BY _ DATE / 1/ �3 <br /> ADDITIONAL COMMENTS: j �I <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPE <br /> INSPECTION BY DATE INSPECTION BY DA <br /> CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />