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Ai 0t SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICE USE;;.:-v, ° "",OW 16,01 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> + APPLICATION FOR WWI CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued 7 <br /> (Complete In Tri=plicate) <br /> Application is evd6y 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 Mules and Regulations of the San Joaquin Local health Dis;rict. i <br /> JOB ADDRESS/LOCATION � . . � �. f' �n .. t . lil cases TRACT . <br /> Owner Is Naaaae <br /> Phone 361-4:k2 <br /> Address a' Gity , - <br /> ,r , <br /> Contractor's / License #f Phos► <br /> _.. ' <br /> ILL IZA-Z <br /> TYPE OF WORK (Check) N w WELL DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> INSTALLATION /�FUME' REPAIR `/�` PUMP RBPLACSM f <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF' .LL CONSTR 1' CIF'I TIES <br /> Industrial � ! Xe Tool D; a: of Well Excevect3otef LL <br /> ' <br /> Domestic/privata, abDrily Dia,76f Well Bing ,: <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotar$� Type of Grout <br /> h. Other Other Informatioaa <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Deme <br /> PUMP UPAIR: L7 State-Vork Doane n <br /> ,UFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describer Aerial, and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquiaa.Local Health District <br /> and the State of Calif zil ansAt CLi c►n.:.. as FTEEN 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 be€ore patting the well In use. The above <br /> f information is true to the beast of my knowledge and belief. <br /> j SIGNED TITLE <br /> D W PLOT. PLAN ON REVERSE SIDE: <br /> FOR DEPARTMENT USE ONLY <br /> AASE <br /> r•,—, s <br /> f APPLICATION ACCEPTED BY - DATE <br />' ADDITIONAL, COMMENTS s <br /> PHASE II GROUT INSPECTION PHASE' 111 F INSPE&ION <br /> INSPECTION BY DATE INSPECTION BY DATE - 3 <br /> ""U . F ' A GROUT INSPECTION PRIOR •TO-GROUT,ING, AND­FINAL IW-jCTION. ..._.. ... <br /> Exl4s <br />