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FOR OFFICE USE: ':SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16QI E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone : (204) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3–//S-0K/ <br /> / THIStiPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 43 <br /> (Complete In Triplicate) <br /> — <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. 18622 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION `� r <br /> * CENSUS TRACT <br /> Owner's Name 5,on 4 <br /> Phone <br /> Address <br /> ., City 97" <br /> Contractor's Name <br /> License # %! .3��Phone5 _ <br /> TYPE OF WORK (Check) : NEW WELL ''' DEEPEN J RECONDITION /-7 DESTRUCTION / <br /> PUMP INSOLATION /—/ PUMP REPAIR —/ / REPLACE <br /> Other -- REPLACEMENT— J? <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER , <br /> INTENDED USE TYPE; OF WELL CONSTRUCTION SPECIFICATIONS <br />_ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private DrilledDia, of Well Casing <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 I <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State, Work Done <br /> PUMP REPAIR: ' <br /> State, Work Done -4 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br />[ hereby agree to comply with all1laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> LELL DRILLERS REPORT of the well <br /> Lnformat and notify them before putting the well in use. The above <br /> P8 s f my knowledge and belief. <br />;IGNED r , , ,, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> Z*i�' <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II/ INA�DATE PECTION <br /> NSPECTION BY DATE INSPECTION $Y �` <br /> _ _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN TION. <br /> E H 1426 ' <br /> 7172 iM r.cz <br />