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r - <br /> . i <br /> Ar <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..T_"�,Ok.IIG�`E us 1601 E. Hazelton Ave: , Stockton, Calif.. <br /> PTelephone: (209) 466-6781- T <br /> Lj <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i_� <br /> f3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued : <br /> (Complete- In Triplicate) <br />� Application is hereby Wade t 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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION' ­� CENSUS TRACT <br /> f <br /> ! _ � ' Phone <br /> i Owner's Name <br /> -4�7 = /!'k ;rT City C� <br /> Address �� �- <br /> f ? - T Phone <br /> License,��_ .� ,3?3 <br /> Contractor's Name <br /> r TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN I_I RECONDITION I_I DESTRUCTION /? <br /> PUMP INSTALLATION / P1,'`MP REPAIR '/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAi�IK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k � r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 5pECIF- 7 ONS <br /> Industrial Cable Tool Dia. of We13 Excavation <br /> Domestic/private Drilled.-- Dia. •of-We11--Casing__ G <br /> Domestic/public Driven Gauge of Casing <br /> .,Gravel. Pack Depth of Grout Seal a� <br /> Other y G <br /> Irrigation f ;- }Rotar Type of Grout <br /> Other Other Information <br /> tom° <br /> PUMP INSTALLATION: Contractor <br /> • E � . H.P. � <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done <br /> PiIMP '"�EPAIR• /'"State Work Done Lv'' <br /> L <br /> I .DF-TRUCTION OF WELL; Well-Diameter .. . "`• <br /> Approximate Depth <br /> Describe Material and Procedure *� <br /> with all Paws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply <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 <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 /> SIGNEDTITLE F` - o� <br /> i <br /> D2AW PL T �-PLA� ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' <br /> APPLICATION ACCEPTED BY <br /> 1 ADDITIONAL COMMENPHASE I INAL INSPECTI N <br /> P SPECTIO DATE � -. <br /> ' INSPECTION BY ATUo� <br /> INSPECTION BY <br /> CALL FOR A I �GO NG AND FINAL INSPE N. <br /> 1 5/731m <br />