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t I. <br /> N, <br /> � PSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 30_L70FF10E 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 1 YEAR FROM DATE ISSUED Date Issued -31- )3 <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION O� � s O 'Oe rro CENSUS TRACT <br /> Owner's Name Phone <br /> 1 .S' 1 <br /> Address --_ _ l r�. .,.., C�fL City . . 7_r� r� <br /> Contractor's Name License # !0Z 7 Phone 2.- 71, 7 <br /> � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' OTHER <br /> ff,� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _X 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 Grout3 <br /> Other Other Information- <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump e,�. H.P. J <br /> PUMP REPLACEMENT: j / State Work Done <br /> P /)CJ' State Work Done <br /> .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 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 /> informatio is truce to .the best of my know dge an elief. <br /> R S IG CG%'/ E ' <br /> I <br /> ( W LO AN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE Zza <br /> ADDITIONAL COMMENTS: <br /> PRASE II G OUT INSPECTION PHASE II F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 4 a <br /> CALL FOR A GROUT-INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> Y7 LT 7 /.7C LI`Y'27tii <br />