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SA14 JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby i-iiade 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 Sark Joaquin <br /> County,.Ordi.nance No. ,1862�and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,3 <br /> 4 , , . A 160: o05 - od,-0-1 <br /> , 05- - <br /> JOB ADDRESS/LOCATION A--oc--� <br /> CENSUS TRACT 11 <br /> Owner's Name I OFF Phone, ( <br /> Address City <br /> Contractor's Name <br /> License #) 73Phone34 <br /> _4LIJ <br /> TYPE OF WORK (Check) : NEW WEL DEEPEN '/ /.., RECONDITION DESTRUCTION /-7 <br /> PUIM2 INSTALLATION RUMP REPAIR jW PUMP REPLACEMENT <br /> 4: <br /> DISTANCE TO NEAREST: SEPTIC �IUNKi SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial CableFool Dia. of Well Excavation <br /> Doi-,iastic/private i Drilled Dia. of Well Casing <br /> - Donestic/public I Driven - Gauge of Casing <br /> Irrigation i Gravel ,-Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Others Other Information <br /> P -T INSTALLATION: <br /> UN Contractor <br /> Type of. Pump H.P. <br /> PUMP REPLACEI�M-NT: State Work Done <br /> A--IR­' <br /> Work D�=—L,�e <br /> PU�T-'�ZP State W6 <br /> DFvTRUCTION OF WELL: , Well- Diameter Approximate Depth <br /> ' Describ;e Material and Procedure <br /> I hereby agree to comply with �all laws and regulations of the San Joaquin Local Health District <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, <br /> I will furnish the San Joaquin Local Health regulatingtrict a <br /> WELL- DRILLERS REPORT of the well and notify them lbefore putting the well in use. The above <br /> informationtrue to the best of my knowledge and belief. <br /> ;j <br /> SIGNED g� _ TITLE <br /> (DRAW PLAN PLAN ON REVERSE SIDE) <br /> FW/fiEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACC DATE 2-- <br /> ACCEPTED BY <br /> ADDITIONAL Co,,hiENLITS <br /> P11ASE 11 P PHASE III/FINAL INSPECTION <br /> INSPECTION BY V ATEV INSPECTION BY 7 Z, DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 V 16I)rl 5/731M <br />