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— 4 <br /> SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOE:OFFI L: 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 -Zs <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 /> JOB ADDRESS/LOCATIONd / AW <br /> _ CENSUS TRACT <br /> Owner's Name a6 l Phone <br /> Address �. /f� City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION J <br /> PLXMP INSTALLATION / J PUMP REPAIR ,/ J PUMP REPLACEMENT <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TAINK 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 /> q� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout - <br /> i Other Other Information • <br /> r <br /> s <br /> t <br /> PUMP INSTALLATION: Contractor ®c_b <br /> i Type of Pump H.P. ' <br /> PUMP REPLACEMENT: State Work Done stc O [W evoAxe,h <br /> a PUMP REPAIR: / J State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />�i <br /> i <br /> j 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 District a <br /> a WELL DRILLERS REPORT of the well and notify them beior putting the well in use. The above <br /> 11 information is true to the best of my kn ed and bel' f. <br /> SIGNED E <br /> (DMW BLOTPLAN ON R E SIDE) <br /> OR DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL C010JENTS: <br /> PHASE II GROUT INSPECTION PHAS . III/FINAL INSPECTION <br /> y INSPECTION BY DATE INSPECTION BY DATE . .�. -„ZJ <br /> F - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . .. . ..,. 5/.7 31rtt` <br />