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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.*'OIT ICL USE: 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 l YEAR FROM DATE ISSUED Date Issued _3-1z <br /> (Complete In Triplicate) <br /> Application is hereby riade 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 Ordinance No. 18.62 and the Rules and Regulations of the San Joaquin. Local, Health District. <br /> a S'-,-1 ' <br /> JOB ADDRESS/LOCATION r _1ra16c--G #CENSUS TRACT4W <br /> Owner's Name Phone <br /> Address �1� ` Y . <br /> License #c2V <br /> Contractor's Name 1(,-/Phone����!— <br /> TYPE OF WORK (Check) - J�NEW WELL DEEPEN _/ RECONDITION / DESTRUCTION /- <br /> PUMP INSTDATION / PUW REPAIR/-7 PUMP REPLACEMEI3T /-7 <br /> — — <br /> Other ./ 1 <br /> f3 <br /> DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k 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 /> a Other Rotary Type of Grout _ <br /> I�. Other Other Information <br /> 15e- <br /> PUMP INSTALLATION: Contractor `Type ..of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done • <br /> a <br /> PiIMP PAIR:... ...: /_ -sSta-te Work Donee. <br /> R DFgTRUCTION 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 c etion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL ILLER&PORT of the well and notify them before putting the well. in use. The above <br /> inform ion td the best of my knowledge and belief. J2 <br /> E SIGNED <br /> TITLE <br /> # IM. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i <br /> i <br /> k FOR DEPARTMENT USE ONLY <br /> iHA� SEI <br /> PLICATIOI ACCEPTED BY DATE <br /> } DITIONA11 COMMENTS: <br /> PHASE III1GROUT INSPECTION �^ PHASE III/FINAL INSPECTION <br /> ., <br /> NSPECTION BY A DATE INSPECTION BY DATE�� <br /> AIM' .&OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M U <br />