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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cal-if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.>�_���1p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / ) <br /> 3 <br /> I (Complete In Triplicate) <br /> Application ie hereby made do 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. 3862 and the Rules and Regulations of the San Joaquin Local: Health District. <br /> JOB ADDRESS/LOCATION /�_G I D <br /> i CENSUS TRACT <br /> Owner's Name X A 114 AC1 S Phone 416 <br /> Address lc4eo& Iq City G <br /> i <br /> Contractor's Name License # � Phone 4,,f <br /> TYPE OF-WORK (Check) : R NEW WELL-:/-_7­i--DEEPEN/_/ RECONDITION /-- DESTRUCTION/']�-- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other. / / <br /> DISTANCE TO NEAREST: SEPTIC' <br /> TANK SEWER L <br /> iINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL UN <br /> Industrial CONSTRUCTION SPECIFICATIONS .F <br /> # Cable Tool Dia. of Well Excavation <br /> _ Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout <br /> " Other Other Information ' <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump <br /> � H.P. oY� <br /> PUMP REPLACEMENT: State Work Done ,.r��ej�f <br /> PUMP REPAIR: / J State Work Done <br />=��JE3TR[3CTION� OF.WEI:I;.' `We.1T�Diamete:r'`"" ;••�' <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local Health District <br /> and the State -of California pe.rtaining,.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 Distritt 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 <br /> TLE <br /> 4 �AWPLOT P ON REVERSE SIDE <br /> FOR <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , DATE 7 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ - <br /> CALL FOR A GROUT INSPECTION 'PRIOR TO GROUTING AND FINAL INSdk6CTION. <br /> E H 1426 <br /> 7/72 1M ^: ` <br />