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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF-OFFICE USE. 1601 E. ,Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466 -6781 <br /> APPLICATION POP, WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7- <br /> (Complete In Triplicate) �gJ loo—off <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 /> ' 777 xS. rs ;� � <br /> JOB ADDRESS'/LOCI'�I0�3 � u �!f� CENSUS TRACT <br /> Owner's Name ,.;j� i rt xx k i Phone <br /> Address `C�► �C Cityo <br /> Contractor's Name. License # Phone <br /> i <br /> TYPE OF WORK "(CheeQ Q. NEW' WELL /7/ DEEPEN '/—/ RECONDITION f_1 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR 0 PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY v <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER La' <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 /> Domestic/public Driven Gauge of Casing ' •� <br /> -- _- ZC 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 R,t or H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZPAIR: /77- State Work Done <br /> ,DFNTRUCTION 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 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._knowled an elief. <br /> SIGNED ���'" - ITLE <br /> W PLOT LAN ON R RSE SIDE) <br /> FOR DERAkTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY leDATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION P I AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE Z <br /> , CALL FORA GROUT-INSPECTION PRIOR TO .GROUTING AND: FINAL INSPECTION. �I� <br /> r u 140r, r 17't-- <br />