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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF. OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> E: _. . Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL;CONSTRUCTION OR PUMP PERMIT Permit No. 70-��&) <br /> THIS PERMIT EXPIRES 1 'YE4_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 Vocal Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NamePhone ^ % 3 1 -_0-7�12 <br /> Address City <br /> Contractor's Name G 4_� - License # hone;' <br /> TYPE OF WORK (Check) : NEW WELL J D EN / RECONDITION / DESTR CTION <br /> PUMP INSTA LA2IO / LW REPAIR / / REP ACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK S VER LINES PIT <br /> SEWAGE DISPO L F CESSPOOL/SEEPAG T � OTHER <br /> INTENDED USE TYPE QF LL CONS CTI SPECIFICATIONS <br /> Industrial CabiKaol Dia. of Well Ex va ion ' <br /> X_ Domestic/private led Dia. of Well Casing <br /> Domestic/public iv Gauge of Ca <br /> Irrigation vel Pack Depth of Gro t <br /> Other to Type of Grou <br /> 0 er Other Inform i <br /> PUMP INSTALLATION Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f State Gdor Done <br /> PUMP REPAIR: _ State Work once <br /> IF .DF.qTRUCTION OF WELL: Well Dia ter Appxox teDepth � - <br /> Describe Material and Procedure <br />` I hereby agree to comply it a laws and regulaiCions of the San Joaqu 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D T <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.F' <br /> E H 1426 5/731M <br />