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�cl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70I'.6FFICE USE: 1601 E. Hazelton,Ave. , Stockton, Calif. <br /> .1 Telephone: (209) 466-6781 <br /> AP LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I - <br /> THIS PERMIT EXPIRES 1 YEAR 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. c1.862>and .the. Rules and Regulations of the San Joaquin Local Health District. ' <br /> 1 <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name ^ 0 I tir'l� -='� - _ Phone <br /> Address City <br /> Contractor's Name License Pho <br /> i vvv <br /> TYPE OF WORK (Check) : NEW WELL / ' DEEPEN/% RECONDITION l I DESTRUCTION I7 <br /> PUMP INSTAI UTION PL'ME' REPAIR / / PUMP REPLACEMENT I� <br /> 0ther' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> /Aomestic/private ri.11ed Dia. of Well Casing <br /> Domestic/public --rDriven Gauge of Casing ; <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other �. Rotary Type of Grout . <br /> Other Other Information ' <br /> 4 <br /> I PUMP INSTALLATION: Contractor +� <br /> Type,of Pump H'P' <br /> i <br /> PUMP REPLACEMENT: / / "State Work Done <br /> I.PUMP 'CEPA <br /> State Work Done ' <br /> epA proximate De th `_ <br /> t FgTRUCTION OF WELL: Well Diameter � X PP P' <br /> escribe Material and Procedure <br /> i li✓ <br /> I hereby agree o comply with all laws and regulations of the San�oaquin`Loca1 Health District <br /> and the State of California1pertaining 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 /> a 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 TITLEV <br /> `j (DRAW PLOT .PLAN ON REVERSE SID j <br /> FOR DEPARTMENT USE ONLY J <br /> P1I.ASE I 7(l <br /> l. <br /> APPLICATION ACCEPTED -BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> 5 PHASE I OU PECTIQiv PHASE I INAL SPECTION t <br /> INSPECTION B t E 3'7v INSPECTION By TE/.Z-sem 7,6 <br /> CALL FORV GROUT NSFECTIO -PRIOR TO- GROUTING AND FINAL INySPECTION. <br />