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�P- SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> For.:OFFICE USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 -_5 "+ <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l�'___�_____ <br /> THIS PERMIT EXPIRES 1 YEAR FROMDATE ISSUED Date Issued <br /> Nf (Complete In Triplicate) <br /> Application is hereby made t6 the San Joaquin Local Health District for a permit to construct r <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION. <br /> J i Phone <br /> owner's <br /> Owner's Name <br /> City <br /> Address <br /> Contractor's-Name; <br /> -Lice-ase �__/_&ZG< .Phone Gz-SSJJ <br /> 3 <br /> TYPEAOF WORK (Check) NEW WELL'��- DE PtNEJ f `- RECONDITION I I DESTRUCTION I�T <br /> PUMP INSTALLATION / PUMP REPAIR/ I PUMP REPLACEMENT 1T <br /> Othert-I% 1i <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 /> _ <br /> Industrial ;° -- Cab1e X001 'Dia_:of Well Excavation <br /> Domestic/private T Tilled f ,: 'D1a•_�`-Well Cas:in _ -- <br /> S <br /> Gravel P Gauge ofttiCas ing,L—J oL {` <br /> Y'C <br /> Domestic/public % <br /> Ir ri ation <br /> ' ack Depth of Grout Seal <br /> g Rotary ° c ! tr ,-Type of lout } <br /> .Otber Other Other. Formation 9 <br /> � <br /> PUi�iP INSALLA�ION Contractors "` - " a H P. <br /> Type of"Pump <br /> ems—,--�.. „—�. i F j. •..."—� -':�9F, �+ , <br /> PUMP REPLACE1�fEN'T: / ' Skate Work Done <br /> PUMP-,EPAIR: � I�~;I -S ate Work Done _ <br /> + t Depth <br /> . . °'Ap t0ximate <br /> # ,DFcTRUCTION OF .WF,LL:'- ': Well Diameter' r �, <br /> } Describe`,Mater ial. and Procedure;., y t <br /> I hereby agree.�to comply,,taitti .all laws' and regulations the.:San Joaquin Local Health District <br /> and" the,State of Ca i£orr►ia`;:pertaznin*- to or regulating well''constructiciri. Watkin FIFTEEN DAYS <br /> w <br /> after complet�oti iof my work on a new well, I will furnish the San Joaqutri, Local Health District- a <br /> WELL DRILLERS REPORT of the .well and no them before'-putting:the welt ,in use. The above <br /> : knowledge and belief. r: <br /> a information�is true.;to the best of 'my y S <br /> SIGNED C ' �: C' e .' TITLE <br /> ,i „ * <br /> (DRAW "PLOT PLAN O PEVERSE SIDE - <br /> FO t DEPARTMENT i#SE;:ONLY- s. <br /> PdASE`I {' rt �'' ,^ ► ,DATE <br /> c: -APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: sy :� "� �. P S I FINAL INSPECTIO n <br /> P E �_IGOUT INSPECTION INSPECTIO�I`.BY DATE <br /> r INSPECTION BY f DATE 4 <br /> CAUL, FOR A GROUT INSPECTION PRIOR TO, GROUTING AND FINAL,,TNSP ON;-.- r � r <br />