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SAN JOAQUIN LOCAL UALTH DISTRICT <br /> ' FOF. OFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7AL-l.�SSG. <br /> THIS. PERMIT EXPIRES 1- YEAR .FROM DATE ISSUED Date Issued 7-Z3/I <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 trade in compliance with San Jaaquin <br /> County Ordinance Nog. 1862.rand the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , CENSUS TRACT <br /> �t <br /> Owner's Name Phone ' <br /> Address City <br /> Contractor's. NamePl ! LicensePhon e <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/% RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION { / PAW REPAIR '/ { PUMP REPLACEMENT <br /> � Other / / ...�" — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> K�,... CA <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Lr <br /> W,�.. Industrial Cable Tool Dia. of Well Excavation (,V <br /> +1f <br /> Domestic/private 'Drilled Dia. of Well Casing U)Domestic/public Driven Gauge of Casing <br /> - � Irrigation Gravel Pack Depth of Grout Seal D <br /> Other Rotary Y Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractore�t. <br /> Type of Pum <br /> PUMP REPLACEMENT: /7 State Work Done <br /> F PUfMP -tEPAIR: / / State Work Done f <br /> , l DJamet �J roximate Depth OF Wei <br /> v <br /> � . Describe Mat ala Procedure <br /> R <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> arid the State of California pertaining to or regulating we11''construction. Within FIFTEEN DAYS <br /> P g g g <br /> after com- e tio6'of my work on a new well, I will ,fu 'ish 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 /> SIGNEDX11,,@ _ TITLE <br /> y k (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> r P1IASE I <br /> APPLICATION ACCEPTED �BY jIf DATE1/17 <br /> ADDITIONAL COMMENTAf <br /> -- ' I_ C T NSPECII <br /> HAS /F. AL N5PECT <br /> INSPECTION B �INSP�EC <br /> DATEINSPECTION BY �€o- DATE <br /> P/ <br /> CALL, k'0 AON PYOR�'TO'GROUT <br /> INGAND FINAL I TON. <br />