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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OF. OFFICE USE: -kll'1601 E. Razelton Ave. , Stockton, Calif. ./ ,a� 7 101, <br /> r Telephone: (209) 466-6781 y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Z --,� 7/ A)) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued S - 7 <br /> �F (Complete .In Triplicate) <br /> Application is hereby made. to the San Joaquin Local Health District for a permit to construct <br /> and/or install thework herein described. ' This application is made in compliance with Sant Joaquin <br /> County Ordinance NIo. 1862 and the Rules and Regulations- of the Satz Joaquin Local Health Ois�rict. <br /> Ji CENSUS TRACT <br /> JOB ADDRESS/LOCATION �e <br /> .ii . <br /> Owner's Name � Phone <br /> Address _ City -- <br /> , <br /> License 4�,2vv7 Phone -d <br /> Contractor s Name;,, ��Com„ � �r!'r "' �� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /- T <br /> PUMP INSTALLATION /s PUREPAIR / / PUMP REPLACEMENT /� <br /> MP <br /> Other <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ° SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> !! f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ;; Cable Tool Dia. of Well Excavation <br /> '14Domestic/private Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation .11 <br /> rrigation .11 Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout " <br /> I Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> ,i Type of Pump H.P. <br />` PUMP REPLACEMENT- State Work Done <br /> PUMP `tEPAIR: / /- State Work Done — <br />` ,DFI-TRUCTION 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 <br /> after completion .of m rk on a new well, I will furnish the San ,Joaquin Local Health District a <br /> WELL DRILLERS REPO of the well and notify them before putting the well in use. The above <br /> information to the bes :. .Of—m kn. ledge and belief. <br /> d L <br /> SIGNED' TITL _ - <br /> -q ( IDE)DRAW PLOT PLAN ON REVERSE S <br /> d <br /> FOR DEPARTMENT USE ONLY <br /> a PHASE I �! <br /> APPLICATION ACCEPTED BY DATE J-1--2-717 <br /> `t ADDITIONAL COMMNTS: <br /> P III—ROUT INSPECTION PRKSE III/FINAL INSP ION <br /> INSPECTION BY DATE 3[J�7 __ INSPECTION BY '7.-1U- �L_ DATEWT <br /> i L--CALL-F'OR.A•GRO'UT.-INSPECTION-PRIOR TO GROUTING AND .FINAL INSPECTION. 5/731M <br />