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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. O1 FICL' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedjc� <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 1 �/ / ' -(N-5 7a.-.Ir 'Al 8611' —aml_- CENSUS TRACT <br /> Owner's Name4%. (a:z raZ4 s Phone V ^2o3 w- <br /> Address f City ' <br /> Contractor's Name �a License # 7U,Z Phone <br /> TYPE OF WORK (Check) : NEW WELL /T,;?�DEEPEN '/ / RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 9 <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing /O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP 'ZEPAIR: /% State Work Done <br /> ,DFGTRUCTION 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 D ERS PORT of the wet and notify them before putting the well in use. The above <br /> inf m tion tr a to the be of my knowledge and belief. <br /> SIGN O'f? TITLE <br /> _(DRAW'FLbT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER BY DATE- � fG� <br /> ADDITIONAL COMMENTS: <br /> PHASE II Gk2C PHA EINAL SPECTION <br /> INSPECTION BY ATE INSPECTION BY TE �y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M ,� <br />