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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k SFO .:OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. tJ <br /> 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 /> and/or install the work herein described. ' This application is made in compliance with Sari Joaquin <br /> County Ordinance No. l$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONbct- CENSUS TRACT <br /> Owner's Name Phone <br /> Address S Q City I <br /> Contractor's Name License # &A3,12 Phone .4261_ <br /> .TYPE OF WORK (Check) : ANEW WELLDEEPEN / / RECONDITION / / DESTRUCTION f_7 <br /> "kMP INSTALLATION /% PUMP REPAIR / / PUMP REPLACEMENT /- <br /> FO %then 1 --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYt. i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> JNi f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial I // <br /> Cable Tool Dia. of Well Excavation` ) <br /> Domestic/private Drilled Dia. of Well Casing it <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation --- Gravel. Pack Depth of Grout Seal. <br /> Other �� Rotary Type of Grout <br /> Other Other Information d <br /> PUMP INSTALLATION; Contractor .� <br /> Type •of Pump a' H.P. <br /> PUMP REPLACEMENT: / State Work Done ? E t <br /> PUMP 'tEPAIR: _. Lj State Work Done ' a <br /> ,I?F�TRUCTION 4F DIE L: 4ell Diameter i <br /> Approximate Depth <br /> Describe Material and Procedure <br /> F` IIS <br /> I hereby .agree to comp <br /> ly':. with all laws and regulatibns of .t-ie'- SAh Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS i <br /> after completion of my work on a new- well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of!(the well and notify themlbefore putting the well in use. The above a <br /> information is true to the best of my knowledge .and be,lief.____j <br /> SIGNED , d r <br /> TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> PRASE I <br /> `I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPT BY III DATE <br /> ADDITIONAL COQ - ;p <br /> P I OUT IN EC'I'It3NIIl/.FINAL INSPEG 0 <br /> 'INSPECT DATE _I �xINSPECTION�$Y `_`_ DATE. <br /> - GALL' FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INS ION. <br /> E _H 1426 j� _. - w. <br /> C�171tiu <br />