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alp <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IOI, <br /> FF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> F Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueds <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 /> .SOB ADDRESS/LOCATION a5 Si SCi tC CENSUS TRACT I <br /> Owner's Name ` Phone pprry� <br /> f s ���'lplJ J <br /> Address 5 $'U JLe&r,e-41 City !�1' DQ <br /> Contractor's Name WOODS <br /> s <br /> Y v icense Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION KI PUMP REPAIR -/—/ PUMP REPLACEMENT /_7 <br /> Other V-7 — <br /> f. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> € V► <br /> NTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial lk- Cable Tool Dia, of Well Excavation W <br /> Domestic/private i Drilled Dia. of Well Casing (n <br /> Domestic/public { Driven Gauge of Casing A _ yi <br /> !r Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout p <br /> Other -Other Information <br /> WOODS ' <br /> PUMA' INSTALLATION: Contradtor <br /> Type of Pump H•P• 1Q__ <br /> PUMP REPLACEMENT: <br /> F7 State Work Done <br /> ru <br />,DFcTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 "construction. Within FIFTEEN DAYS k <br /> after completion of my 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE _ —� �1 <br /> ZI (DRAW PLOT PLAN ON REVERSE SIDE) "- <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � t <br /> APPLICATION ACCEPTED BYh DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TT,, aOUT INSPECTION/ PHASE II /FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BYDATE fTll <br /> CALL VOR A GROUT INSPECTION PRIX TO GROUTING AND FINAL INSPECTION <br /> . <br /> E H 1426 <br />-M� - m- /731M <br />