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y SAN JOAQUIN LWALALTH DISTRICT <br /> FOf.;OFFICk; USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k 4 (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 /> t County Ordinance No. 1862 and e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G <br /> CENSUS TRACT <br /> �1,ee G <br /> a i <br /> Owner!s`.Name ALam. i a�,All M it rl0 <br /> Y <br /> Phone <br /> ea� <br /> Address Q _ <br /> City <br /> .. . �. �`� <br /> ACtractor's Name License 0-Phone ' <br /> d <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN —[ RECONDITION %f DESTRUCTION /_7PUMP INSULATION PUMP REPAIR <br /> REPLACEMENT <br /> �P <br /> other / <br /> ^^' 4 <br /> DISTANCE TO NEAREST: SEPTICATA14K SEWER LINES PIT PRIVY <br /> SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PITY OTHER r <br /> i <br /> m <br /> INTENDED USE TYPE':OF <br /> :OF WELL CONSTRUCTION SPECIFICATION$ <br /> � Industrial ""Cab7.e Tool Dia. of Well Excavation <br /> .i <br /> Domestic/private ; Drilled iiia. of Well Casing r <br /> Domestic/public r � Driven Gauge of Casing c P <br /> Irrigation Gravel Pack Depth of Grout eal <br /> Other S <br /> �J Rotary Type of Grout <br /> i <br /> Other, Other Information ' r�{ — <br /> PUMPINSTALLATION: Contractor <br /> Type of Pump <br /> i H.P. - <br /> PUMP,REPLACEMENT: „ ��!J State Work Done <br /> • 'J. / State-:Work Done <br /> ,DFNTRUCTION-OF-WELT:..-----We1-1--D3ameter . , _ _ <br /> Describe Material and ProcedureP.Proxamatme Depth T� <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 s <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 ab <br /> information is true to the best of my knowledge and belief. ov <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APP~-LICATION ACCEPTED -BY i <br /> ADDITIONAL COMMENTS: J DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N a <br /> INSPECTION BY DATE INSPECTION BY DATE -d <br /> CALL FOR A GROUT INSPECTION PRIOR TO-: GROUTING AND FINAL INSPECTION. <br /> E.-H-1426 F <br /> r P7-I--- <br />