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{ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.;OrI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> `- ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is he rade to the San Joaquin Local Health District for a permit to construct <br /> and/or install therwork 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 /> I <br /> JOB ADDRESS/LOCATIONf F - 1/4 6 CENSUS TRACT <br /> -- 7 V . <br /> Zl <br /> Owner's Name <br /> � <br /> Phone <br /> o7 !�? r City <br /> Address / <br /> yt <br /> Contractor's Name License #, �y Phone# � <br /> a <br /> ' T�DEEPEN / / RECONDITION_/_/ DESTRUCTION /-7 <br /> TYPE OF WORK (Check) : NEW WELL fL� _ <br /> PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other,,/ / i <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <br /> INTENDED USE --TYPE -OF WELL CONSTRUCTION SPECIFICATIONS N-% <br /> Industrial 'Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> k Other Rotary Type. of Grout 1 X <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Dome <br /> PUMP 'REPAIR: State Work Done <br /> E pF,"-TRUCTION OF WELL. Weli Diameter <br /> 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 we11 ''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 /> / J TITLE � - �7 l�� <br /> 9 SIGNS W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> ^, APPLICATION ACCEPTED BY <br /> 0 ADDITIONAL COMMENTS <br /> PHAS TI PHAS I/FIN NSPECTION <br /> ' INSPECTION BY ATEA _ INSPECTION BY DATE - <br /> CALL FOR E TION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> n IT 1 L')G <br />