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SAN J'OAQUIN LOCAL'HEALTH DISTRICT rct r <br /> For.WFICE USS:: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: ,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued tv - <br /> (Complete In Triplicate) <br /> G 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 Ordiraanct No'.o 1862 .and the Rules .arid. Regulations of the San Joaquin Local: Health Dist�i.ct. <br /> .TOB ADDRESS/LOCATION _PdCENSUS TRACT <br /> Owner's Name Phone <br /> Address n . City . <br /> Rd <br /> Contractor's Name . Dn_oa�(VA— License -4=1�Phouk41 <br /> I. TYPE OF WORK (Check), .!.NEW WELL Y1K7_ DEEPEN /_7 RECONDITION /—/ DESTRUCTION <br /> PUMP INSTALLATION / / 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 /> INTENDED USE TYPE OF WELT, CONSTRUCTION SPECIFICATIONS <br /> f Industrial " , Cable Tool Dia. of Well Excavation (7 <br /> /prx.vate� <br /> .Domestic Drilled Dia. of Well. Casing <br /> - -_- <br /> Domestic/public Diiven Gauge of Casing .- <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other Rotary Type of Grout <br /> Other Other Information rt <br />' PUAiP INSTALLATION: Contractor <br /> i : Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PU '�tEPAIR: / .� State Work Done <br /> ,D l RUCTION 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 weil ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a neer well, I will furnish the San Joaquin Local Health Distric 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. IV <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> •OR DEPARTMENT USE ONLY <br /> k PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: OF <br /> PHASE 11 GROUT INSPECTION PHA III/F NAL INSPE • ON• <br /> INSPECTION BY DATE INSPECTION Br DATE <br /> e CAIt *FOR-A,G OU -,INSPECTION :PRIOR .TO, GROUTING.AND FINAL.INS ECTION. <br /> E H 1426 5/731M <br />