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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. ICF: USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/ -73 <br /> (Complete In Triplicate) f L�3_2-2-0_ r <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> 3'3/ 6. <br /> JOB ADDRESS/LOCATION MILW CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name _ License ���lf PhoneiC <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other UV <br /> DISTANCE TO NEAREST4 SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ((j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial T Cable Tool Dia. of Well Excavation t ' <br /> Domestic/private Drilled Dia. -of Well Casin CY W - <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth c Grougk a <br /> Other Rotary TypGr ut - <br /> Other 0 he ma $` <br /> 1 PUMP INSTALLATION: Contractor a `off <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done �r <br /> PUMP 'ZEPAIR: / State Work Done <br /> .DFCTRUCTION OF WELL: Well Diameter All Approximate Depth <br /> Describe Material and Procedure , <br /> I hereby agree to comply with aM 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 /> SIGNER _ / c, TITLE X <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> EPARTMENT• USE ONLY <br /> PHASES,;[ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II _ PHAS -IN' INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> #w//?7/ j <br /> E H 3.426 5/731M <br />