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-G SAN JOAQI,IN.LQCAL HEALTH DISTRICT " <br /> FOR OFFICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3-333-4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,7-,12 W <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 a d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADbRESS/LOCATIO /-a �r � CENSUS 'TRACT <br /> Owner's Name Phone <br /> Address /� p ���� / <br /> --�=�--•� � �- —_. ,_... __ _ City <br /> Contractor's Name <br /> - � License # Phone <br /> TYPE OF WORK (Check) : NEW WELL a_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /?- _- <br /> PUMP INSTALLATION / / 7PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 -" <br /> DISTANCE TO NEAREST: SEPTIC TANK P SEWER LINES PIT PRIVY ° <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> _ Industrial y_ Cable Tool :; Dia. of Well Excavation i <br /> _ Domestic/private Drilled Dia. ,of Well Casing /2 " <br /> Domestic/public +: Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other Rotary Type ofTGrout <br /> Other Other Information <br /> i 4 <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ERUCTON OF W : Well Diameter <br /> ,P5TIELL <br /> _-. Approximate Depth <br /> I Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <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 SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />,.APPLICATION ACCEPTED BY Y w DATE /��✓ <br /> k ADDITIONAL,,COMMENTS: <br /> '" PHASE II GROUTrINSPECTION PHAS III F NAL INSPECTIO { <br /> INSPECTION BY DATE. INSPECTION BY DATE <br /> 1577 3 <br /> CALL FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M <br />