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y <br /> . �' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL-(ONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS <br /> o. —THIS PERMT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (Complete In Triplicate) ©rel-- �030�-0 <br /> Application is'-hereby"made to the• San Joaquin Local Health District for a permit t construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 186 and the Rules and Reg latio s of t e San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION► ENSUS TRACT <br /> Owner's NamePhone'. <br /> Address City , t <br /> " License #f� Phone <br /> Contractor s Name <br /> TYPE OF WORKW(Check): NEW WELL / / DEEPEN / [ RECONDITION DESTRUCTION /_ <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> .� Other <br /> DISTANCE TO NEAREST: SEPTIC TANK £s ;SEWER LINES PIT PRIVY <br /> �.- - —SEWAGE-DISPOS•AL•- FIELD— CES`SPOOL/SEEPAGE^PIT- OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATION <br /> Industrial Dc Cable Tool Dia. of, Well Excavation ' <br /> Domestic/private Drilled Dia, of Well Casing ppp <br /> 4 y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ' Other Other Information ' - <br /> PUMP INSTALLATION: Contractor }� <br /> l t. ' <br /> Type o f Pump ter:t H.P. CJ <br /> PUMP REPLACEMENT: / / State Work Done � .-'dam # �'• <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTIONYOF WELL: Well Diameter _ xt� Approximate Depth <br /> F — Describe. Material and Procedure"h14- r. <br /> I hereby agree to comply with all laws- andVregulat3ons`'of.4the; San Noaquin' Local Health District <br /> and the State -of California pertaining to or regulating well constructivii Within FIFTEEN DAYS <br /> l after completion -of m work on a new well I will ~fujrnisji�he San-Joaquin.+.Local�.Health District a <br /> y tA ..sem ,- <br /> WELL DRILLERS REPORT of the well and notify,*themibefore-iMt-ing the we_11= in use,. The above <br /> information is true io_athe best of my knowledge and beli'ef: "F <br /> SIGNED TITLE <br /> �. (DRAW�PWTIPLAN ON REVERSE SIDE) �." <br /> ._FOR DEPAPTMENT,USE ONLY <br /> PHASE I - + � 1 s DATE <br /> fA'PPLIC ION ACCEPTED:_BY. �: <br /> Ar <br /> 4A1ITIAL COMMENT : <br /> ' PHAS II;GROiTT INSP+ECTION' x,�%a4 <br /> PHASE III INAL INSPECT ON r <br /> 1 .:.. j�� INSPECTION BY DATE 0 <br /> INSPECTI-N BY - - �- <br /> CALL FORA GROUT "ITS ECTION PRIOR TOWWUT.ING"AND FINAL INSPECTION <br /> /72 1M <br /> E H 1426 r +�' - 7 <br />