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f 11 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l FOx..01FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? <br /> ,r ,t. (Complete- In Triplicate) . OG f— f32--!3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> F 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 /> CENSUS TRACT ' S I <br /> r JOB ADDRESS/LOCATION — <br /> Owner's Name N Phone �C�� <br /> Address y`1 r !� igU, -_Ills City �o <br /> s } - License #As � �� <br /> 3L � Phone <br /> Contractor s Nam <br /> m - � <br /> TYPE OF WORK (Check) : *NEW;WELL /T DEEPEN RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> ION <br /> ' Other <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> INTENDED USE j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia. of Well Excavatio5n �S <br /> :]�Domestic]Trivate. " - -; Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 'Irrigation Gravel Pack Depth of Grout Seal. <br /> Other OtY <br /> Rotary Type-pe of Grout <br /> Other Other laformation ' <br /> PUMP INSTALLATION: Contractor <br /> H.P.- <br /> Type of Pump <br /> PUMP REPLACEMENT: - / / ; State Work Done <br /> PUMP "tEPAIR: / /.. ate Work Done' <br /> � <br /> .DF-,TRUCTION' OF `WELL:, '.',Well'b1ameter Approximate Depth <br /> Describe,Materi.al 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 well 'constructi.on. Within FIFTEEN DAYS <br /> after completion_ of my wotk an a new well, I will furnish the San. Joaquin Local Health District 8 <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. <br /> SIGNED TITLE -- <br /> [ (DRAW PLOT PLAN ON REVERSE SID <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I ATE _7 <br /> APPLICATION ACCEPTED BY f <br /> ` ADDITIONAL COMMENTS: <br /> 1. PHASE II G UT INSPECTION PHASE III/FINAL I S CTION <br /> INSPECTION• BY DATE - SIPECTION BY RATE <br /> CALL FOR A,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 1((',,��r� <br />