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A Or `, f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,&F'ICE USE: 16D1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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/LOCATION SW CENSUS TRACT <br /> n <br /> Owner's .Name T,41n geS /1_41 zil &3 Phone <br /> Address /_City �/ „� <br /> pp <br /> Contractor's Name 6.1 License # Phone <br /> TYPE OF WORK (Check),: NEW WELL I / DEEPEN '/ j RECONDITION DESTRUCTION DESTRUCTION /_" <br /> PUMP INSTALLATION _&—PUMP REPAIR / I PUMP REPLACEMENT /7 <br /> T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES16M,- PIT PRIVY <br /> SEWAGE DISPOSA:L_ TELD CESS OOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION-SPECIFICATIONS �! <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of CasingL <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 7 G --e <br /> Type of Pump e. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tUPAIR: / / State Work Done <br /> ,DF'IZTRUCTION 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 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. 5 <br /> SIGNED ? <br /> D PU6 PLAN Off AVERSE SIDE) <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL CO.�IiENTS: <br /> PHASE I1. 0OUT INSPECTION PHASE I ./FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br />