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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1<OF., OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> s-a76',' <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE 'ISSUED Date <br /> (Complete In Triplicate) <br /> Application is hereby rade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the worts 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 5-1400 CENSUS TRACT <br /> Owner's Name d y ra-5--;,T— Phone <br /> Address ®fz 1 }`�/ city <br /> o7a 37�'P �l'�'9'-V- I <br /> Contractor's Name �`��L�� �" ���� License hon <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/�/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR -/—/ PUMP REPLACEMENT /- <br /> e • Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI ONS <br /> ` Industrial � Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> jDomestic/public Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal -15Z <br /> Other Rotary Type of Grout <br /> i Other Other Information ' <br /> i <br /> i, <br /> PUMP INSTALLATION: Contractor L —14 A4 P-�S <br /> i Type of Pump H,P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP VPAIR: - - % State Work Done <br /> i <br /> ;,DFsTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alI 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. <br /> 3 <br /> SIGNED /tat- - TITLE _ r ,.�..,yi✓ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F04 DEPARTMENT USE ONLY <br /> PHASE I <br />.� APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II WOUTINSPECTIO4 PHAS /FIM INSPECTION <br /> INSPECTIOpNBDATE r �3l S� INSPECTION B DATE <br /> CA D FOR AGROU INSPECTI1� PRIOR GR U I G AND FINAL I ION. , <br /> E H 1426 5/731M " <br />