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SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> 0 . OFFICE ilSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> AU 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 - V,C <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 an lations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION s S M. CENSUS TRACT <br /> Owner's Name - Phone <br /> Address City" <br /> Contractor's Name License #2-1:Z4 Phornea <br /> TYPE OF WORK (Check) : NEW WELL J DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION /7� PL'MMP REPAIR / J PUMP REPLACEMENT /-7 <br /> Other J / — <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER L;NES IT PRIVY <br /> SEWAGE DISP SAL FIELD< ( CESSPOOL/SEEPAGE P T t, OTHER �-• <br /> Cpl INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool" Dia. of Well Excavation l/ <br /> ' omestic/private Drilled Dia. of Well Casing (a . /P <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S <br /> Other otary Type of Grout <br /> Other Other Information A P, <br /> PUMP INSTALLATION: Contractor L <br /> jType of ptia <br /> PUMP REPLACEMENT: / / State Work Done <br /> njE W��� IgT3/jNDO/4 pWA/ WCL .-� <br /> ` PUMP UPAIR. / J State Work Done ©w <br /> I — <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> rI 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 any 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 before putting the well in use. , The above <br /> inf rmation is true to the best of my knowledge and belief. <br /> SicNEB TITLECie - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> L/ DEPARTMENT USE ONLY <br /> PHASE I S`z/� p` <br /> APPLICATION By L/N4771 DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II aOUT INSPECTION PHASE-XIIArMAL INSPECTIO <br /> ' INSPECTION BY J ' DATE „� INSPECTION BY DATE, <br /> CALL FOR GROUT. INSPECTION-PRIOR T8 GROUTING AND FINAL I 6PTION. <br /> 1` E H- 1426 S/731M <br />