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I � <br /> g SAN JOAQUIN LOCAL HEALTH DISTRICT . 4 <br /> FO£-:OFFICE. USE: i� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> I�APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued <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 /> � ��- � T -SUS TRA��r©r <br /> JOB ADDRESS/LOCATION I C <br /> Owner's Name II Phone ' � d - <br /> Address City / <br /> ., r <br /> Contractor's name License gZO07Phone ,. r <br />! 0 <br /> TYPE OF WORK (Check)-. �� NEW WELL DEEPEN / / RECONDITION DESTRUCTION /-7, <br /> I:PUMP INSTALLATION / / 'L`I ' REPAIR X­PUMP REPLACEMENT ITT . ,. <br /> i <br /> / / —Other . UA <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES PIT PRIVY •. <br /># SEWAGE AIS SAL FIELD CESSPOOL/SEEPAGE PIT OTHER*' <br /> INTENDED USE 'T'YPE OF WELL CONSTRUCTION SPECIFICATIONS <br />' Industrial i� Cable Tool Dia. of Well Excavation I/iv ' • <br /> j' Domestic/private Drilled Dia. of Well Casing 9115 <br /> Domestic/public I Driven Gauge of Casing L2= lip <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> Other —. ' Rotary Type of Grout <br /> I Other Other Information ' <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 3 'i / / State -Work'"Done <br /> PUMP UPAIR: a . . . . <br /> / / State Work Done <br /> DF"-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> A - -i- Describe M e eria .and rocedure <br />+; I hereby agree to comply with all laws and Ogulatiofs of the San Joaquin Local Health District <br /> and the State of California .pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> af:ter�completion of mi work on a new well, I will furnish the San Joaquin Local Health District a <br /> j WELL DRILLERS REPORT i the well and notify them before putting the well in use. The above <br /> information is to the best of knowledge and-belief. <br /> i iM <br /> i SIGNED TITLE <br /> i� (DW PLOT PLAN ON REVERSE SIDE) <br /> F0 DEPARTMENT USE ONLY <br /> PHASE I r. , ;.. is jl <br /> APPLICATION ACCEPTED ;BY ; DATE <br /> ' ADDITIONAL COMMENTS: <br /> Pi II GRO C PHAS III/,FINAL INSPECTIO <br />'I <br /> INSPECTION 37y TE INSPECTION BY DATE <br /> ` CALL FOR A GR UT Y}TIsPE ON PRI ` <br /> OII TO' OtITIN <br /> i;. 'TEH1426 <br />