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SAN JOAQUIN LOC�L .HEALTH DISTRICT <br /> FF— ° <br /> OT. OF ICt i15L.. <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �,. Telephone: 1204) 466-6781 <br /> _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> Na. <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATIONea <br /> CENSUS TRACT <br /> Owner's Name1��L?. .L � f � JI 110 ..�Le�11p-? Phone 5,3-L-- <br /> Address -Address 11 � s i <br /> City ' <br /> 01 <br /> Contractor's Name License # 11kfPhone -� <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN RECONDITION /_! DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other l <br /> IM <br /> DISTANCE TO NEAREST: SEPTIC TANK V0 SEWER'ILTNES PIT PRIVY <br /> SM4AGE 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 o Drilled <br /> , Dia. of Well Casing i0 \1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack I� Depth of Grout Seal �' <br /> Other } _ �L� - - <br /> Rotary j�. Type of Grout <br /> Other I; Other Information S -_bu a,lze <br /> l <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP, UPAIR: / / State Work Done <br /> ,DF-,TRUCTION OF WELL: Well Diameter q Approximate Depth <br /> Describe Material and Prbcedure <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 willl furnish the San Joaquin Local Health District a ' <br /> WELL DRILLERS REPORT of the well and notify theme before putting the well in use. The above <br /> information is true to tht: best of my knowledge and belief. <br /> I <br /> SIGNED a TITLE <br /> __ _ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I� <br /> APPLICATION ACCEPT�D BY" DATE('% 5-23 . <br /> ADDITIONAL COQ �I <br /> '• ROUT INSPECT ON i PE&SVIIt/ AL INSPECTION <br /> INSPECT BY DATE I INSPECTI DATE <br /> L.w-CALL-FOR�AwGROUT•-INSPECTION PRIOR-TO GROUTING AND.FINAL. INSPECTION. <br /> E H 1426 �/7'37M r4-7 <br />