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7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> lbDl E. Hazelton Ave. , Stockton, Calif.. ' <br /> For: Ol FICA .7 ]=: E I <br /> Telephone; (209) 466-6781 <br /> / APPLICATION FOR WELL CONSTRUCTION OR PUMP PE IT �'mit No. <br /> THk5 PERMIT EXPIRES 'I. YEAR FROM DATE ISSUED Date Issued _n ax <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquiin„local Health District for a permit to constT <br /> .uct <br /> g is <br /> and/or install the work herein described. egulationstonein the SanJaaquinpLocalewith HealthBan n District <br /> County Ordinance No.:,1862 and' the Rules as <br /> ` CENSUS TRACT <br /> JOB ADbRESS/LOCATION.' <br /> Phone <br /> Owner's Name' P” <br /> 0 City ; <br /> Address <br /> f License , Pham 6 <br /> Contractor's Name <br /> 1 <br /> WORK . Check) : NEW WELL / / DEEPEN/�1 RECONDITION / DESTRUCTION /�T <br /> TYPE OF ( PUMP INSTALLATION // PUMP REPAIR I / PUMP REPLACEMENT I-T D <br /> Other` <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK 'Q _ EWER L f3 S . 0 /SET PRIVY <br /> SEWAGE DISPOSAL FIELD ^U CESSP <br /> 00 /SEEPAGE PIT OTHER �U <br /> a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of 77 <br /> Well Casx.11 <br /> Domestic/Private Driven Gauge of Casing <br /> Domestic/public <br />( Irrigation Gravel PeckephoffGrout Seal d ^ <br /> I Ocher <br /> Rotary YP <br /> Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor Ii.p. <br /> Type! of PUMP --�--•� t <br /> PUMP REPLACEMENT: / J State=Work Done <br /> f4066- <br /> PUMP '2EPAIR.: / / to Wor Sone .. _y. _ <br /> d�% .Txi <br /> 3 DF.CTgUCTION OF WEL W ''Diameter/ "" <br /> crilie 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 Califoruia .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 knowledge and belief. <br /> TITLE <br /> SIGNED <br /> ._. (DRAW PLOT PLAN ON REVERSE SI <br /> R DEPART T USE ONLY <br /> PHASE I DATE r�7-7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMNXENTS: PHA FINAL INSPECTION <br /> P Gita T; INSPECTIO ATE <br /> INSPECTION BY DATE INSPECTION BY <br /> � CALI..I'OR A•GROUT INS CTION_PRIOR TO-GROUTING AND-FINAL <br /> - __ _ .�r 9 �� S 2 66 �" 5/731M <br />