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1135o W%. Nn VX0 a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For.—OFFICE USE: L 1601 E. Razelton Ave. , Stockton, Calif. r° T-" qo Telephone: (209) 466-67814APPLICATION FOR WELL CONSTRUCTION OR PUMP PE IT'S a tP�xii► . �v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5� <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 made in compliance with San Joaquin <br /> County 0rdinance_No. l the Rules and Regulations of the San Joaquin Local. Health District. <br /> +1- T: 'S :•Ga yyCo Ali, r CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name ` Phone 1 <br /> C��/y7Cf <br /> city . oQ <br /> Address /0115 114 X/ <br /> U) <br /> Contractor's Name `?�5� License Phone <br /> TYPE OF WORK (Check): NEW WELL <br /> DEEPEN '/ / RECONDITION / / DESTRUCTION IT 0. <br /> PUMP INSTALLATION I I PUMP REPAIR /% PUMP REPLACEMENT l� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEgFIIONS' ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H'P' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DF•�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 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, I will furnish 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 /> f3 SIGNED ? -�- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-'BY DATE , S <br /> ADDITIONAL COMMENTS: <br /> P GROUT INSPE TION P SE II FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A-G OUT INSPECTION PR TO GROUTING AND FINAL INSP ION. ,/ IM <br /> E H 1426 5/ 3 <br />