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SAN JOAQUIN LOCAL-HEALTH nI STRICT <br /> r,o .*OFFICE USE: 1601 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 Tssiicd <br /> (Complete In Triplicate) <br /> Application is hereby mads: to the San Joaquin LocalHealth District for a permit to construct <br /> and/or install the work herein described.•'. This app.lieation is made in compliance with San Joaquin <br /> County Ordinance .No.. 1862 an �d a i4C es d Regu�l,aa on of the San. Joaquin Local Health District.• <br /> /$yp cH� /C . <br /> 3flB ADDRESS/LOCATION � � CENSUS TRACT <br /> Owner's Name Phone <br /> ' f <br /> Address Ole. City <br /> Contractors Name <br /> License//"74�1�1?lhoneS��� i <br /> TYPE OF WORK (Check) NEW WELL / / DEEPEN ,/—/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? I <br /> Other / / — <br /> _ 1 � <br /> DISTANCE TO NEAREST: SEPTIC TAi�1K ,(,40 . SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD l6"Q CESSPOOL/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 Casing.," : <br /> -}o:tte�stxc ub-l-ic--- -�--,i—+—Driven = _-= <br /> /� GaugeofG-asig $ ;....'"""" - <br /> Irrigation 1 Gravel Pack Depth of Grout 'Seal <br /> Other Rotary . Type of Grout <br /> Other Other Information ' �# <br /> PUTT INSTALLATION: Contractor <br /> Type of Pixmp H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: / _/ State Work Done <br /> �L-_ � / <br /> ,DF�T UGTION OF WELL: Well Diamete �.Gy1�I� �� �'tifSP � Approximate Depth <br /> Descri e ter 1 a. d_P.roce`ure• <br /> I hereby agree" to comply with all laws and' r gulations' o1 '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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY _,e" DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II OU INSPECTI N PHASE III/ AL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION BY �TION.fc4hze_)OV <br /> DATF <br /> CALL FOR, A GROUT •INSPECTION-PRIOR TO. GROUTING AND FINAL INS 9`//��� <br /> E H 1426 / �,� <br />