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z T N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �--F--O- .:OFIiCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> } <br /> L4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> a <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 Sant Joaquin <br /> County Ordinance No. 1.$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J <br /> CENSUS TRACT , <br /> Owner's Name Phone ' <br /> Address City . . <br /> Contractor's name MA� License <br /> r <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other/ I <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />'f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �y <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> � Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of CasingNJ <br /> Irrigation Gravel PackDepth of Grout Seal ['] LA <br /> Other �otary Type of Grout o <br /> Cher Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> .� H.P. . <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP 'tEPAIR: State Work Done <br /> ,DFRTRUCTION OF WELL: Well Diameter <br /> Approximate Depth � <br /> Describe Material and Procedure <br /> f <br /> hereby_�agree to cgmply_with _all laws, d_ regulations_of the Sar Joaquin.,Local Health District <br /> and the State of California pertaining to or regulating well '�canstruction. Within FIFTEEN4DA <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 /> SIGNED <br /> TITLE _ <br /> (DRAW FLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR-DEPARTMENT USE ONLY <br /> Z-11 <br /> APPLICATION ACCEPTED .B DATE /-`� /Z�G <br /> ADDITIONAL COMMENTS: 2' <br /> e <br /> PEASE I G OUT INSPE TION d <br /> PHASE I /FIN INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 if /7 1 p <br />