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r <br /> SAN JOAQUIN <br /> , . LO1EALTH DISTRICT <br /> 'kICE U 1601 E. Hazelto �Je.i <br /> O :5n. , <br /> Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3_,3 //P <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ' <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> Counity Ordinance No.' 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB 'ADDRESS/LOCATION 3 J da cam .- 1a� CENSUS TRACT - <br /> Owne 's Name l Phone <br /> Addr ss <br /> _ City <br /> ContIractor's Name License # ne <br /> TYPviOF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATTON /% PUMP REPAIR IX/ PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE_ TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 3 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS w <br /> Industrial Cable Tool Dia. of Well Excavation <br /> k Domestic/private Drilled Dia, 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 /> PUMPiINSTALLATION: Contractor �' � C oct y <br /> Type of PumpH.P: <br /> Uri IV <br /> PUMP,, REPLACEMENT: / / State Work Done <br /> PUMP; `REPAIR: /Ad State Work Done / wile , <br /> ,DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure p <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and ,�he 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 /> WELt" DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true to the best of myknowled an lief. <br /> jl ' <br /> SIGNEDQ�Ak zw LE �+- <br /> {DUE 4LOT PAN ON R SE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE r <br /> ADDITIONAL COMMENTS: <br /> jf PHASE TI GROUT INSPECTION PHA INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR-,A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL I S <br /> E':'H 1426 <br /> 5/731M <br />