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}/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F EOL.:OIIICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br />� ... Telephone:p (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) .2.,-(7- 14-0-16Z <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 <br /> of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t - - : r CENSUS TRACT <br /> Owner's Name Phone S� <br /> Address - <br /> .. City CA9 ! <br /> Contractor's name <br /> License 4 S'�jla` Phone <br /> a <br /> _ <br /> TYPE OF WORK (Check): NEt�1 WELL / EEPEN /�—RECONDITION %_ <br /> PUMP INSTALLATION /t.f [P REPAIR / / PUMP REPLACEMENT <br /> Other �/ { ' <br /> DISTANCE TO NEAREST: SEPTIC TANK ��� SEWEk`'L'INES�fi PIT-PRIVY k <br /> SEWAGE DISPOSAL FIELD,!�70- t,1—CESSPOOL/SEEPAGE PTTA�i OTHER <br /> INTENDED USE TYPE. .OF WELL M <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial �` Cable Tool. Dia. of Well Excavation, <br /> Domestic/private Drilled Dia. of Well Casings' <br /> Domestic/public Driven <br /> Ga of Casing p <br /> rIriigation Gravel Pack Dept�Tbf Grout Seal �� <br /> Ocher x Rotary -- Type of Grout.__ <br /> Other Other Ifrformati�onv <br /> ---- <br /> PUMP INSTALLATION: Contractor Y <br /> Type of Pump - _ H.P: <br /> PUMP REPLACErMNT: / / Stale Work Done <br /> PUMP 'iEPAIR: <br /> L-1 StateTWork LDone <br /> :DFCTRtFCTION.,OF WELL: Well Diameter 1 °, Approximate Depth <br /> Describe Materia'l-.and Procedure <br /> 1"hereby agree to comply with all laws and regulations"66f the San Joaquin/Local Health District <br /> and the State of California pertaining to or regulating we'11 ''construction. Within F'IF'TEEN DAYS <br /> of ter letion f may work on a new wet I will furnish'the_'San Joaquin-Local Health District a <br /> WELL DRrLLERS REPORT of the well and notify them before'putt_9' the well in use.TYi above <br /> information is true to the b of m}�`/�knowledg%�9}d belief. f ' <br /> SIGNED � '�v� G'1 <br /> crF' TITLE <br /> (DRAW PLOT PLAN SE SIDE) y <br /> r FOR-DEPARTMENT USE ONLY = <br /> PHAS , , 1 <br /> APPLICATION ACCEPT BY C:4 DATE <br /> ADDITIONAL COIVE <br /> i P I UT INSPECTI k�INAL INSPECTION . <br /> -73 <br />, INSPE ION BY DATE --� INSPECTION BY DATE - � <br /> - CALL FOR A- GROUT.INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. c <br /> t' E H 142r. _ <br />