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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> T F. O1 k ZCE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7 7W'.1 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> algid/or install the work herein described. - This application is made in compliance with San Joaquinl <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Phone <br /> Owner's Name - <br /> Address t CJ ✓ � City Y tirc <br /> Contractor's Name �,, iC LicenseI'honep <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION I7 s� <br /> PUMP INSTLATION jY4 MP REPAIR/ /. PUMP REPLACEMENT /? <br /> ALy1 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TA1NK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private --- Drilled Dia. of Well Casing 4L . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �ko' Rotary Type of Grout `Y <br /> Other Other Information <br /> PUTT INSTALLATION: Contractor /.y�fr'�,� 11 C•�.e/C --- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />'E PUMP 'REPAIR: / / State Work Done <br /> F DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k 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 Distrito'' <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> ' PRASE I <br /> APPLICATION ACCEPTED BY Zama DAT — <br /> ADDZTIONKL COTE ENTS: <br /> PHASE II GROUT IN ECTION PHASE III/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -L-ZZ <br /> CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION.- <br /> 7 u I L9A 5/731M - <br />