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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> {3F_:OI r.ICE 1601 E. ,Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> Se_ �=t r4�v,� E v/� , - - � : , (Complete In Triplicate) <br /> Application is hereby made. to)the San Joaquin Local Health District for a per to :const uct <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 /> S TRACT <br /> 4JOB ADDRESSILOCATION . <br /> GLS <br /> Owner's Name . , . Phone <br /> City <br /> Address <br /> Contractor's name License <br /> 5 • <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION I I DESTRUCTION /7 <br /> PUMP INSTALLATION 0 PUMP REPAIR'/ I PUMP REPLACEMENT I—T <br /> Other <br /> 4 - <br /> DISTANCE TP NEAREST: SEPTIC TANK/ <br /> �e9 SEWER LINES f(l PIT PRIVY <br /> t3.c•� / >�f &tv.J/r'1- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/ OTHER <br />} <br /> INTENDEb USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -, Industrial Cable Tool Dia, of Well Excavation <br /> A 3omestic/- •rzvate:,- ;. ... r�11ed •_�^�� ,Dia. of Well ..Casing: -- - - <br /> �ome ,ticblic rivenGauge of Casing Gravel Pack Depth of Grout Seal <br /> _ Other � otary Type of Grout <br /> ' Other Other Information <br /> PUMP INSTALLATION: Contractors _ <br /> Type of Pump H.P. <br /> per,, <br /> PUMP REPLACEMENT: / / State Work Done. <br /> f <br /> PUMP UPAIR: / / State Work Done <br /> i F�F�ZTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i5 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 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 /> i 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 /> SIGNED r rje9l TITLE <br /> (DRAW OT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTEDr,BY <br /> DATE , <br /> ADDITIONAL =D1ENTS: <br /> AGROUT <br /> I ROUT INSPECTI N PF3ASE I/FIN INSPECTION <br /> INSPECTIONB1 DATE ."b INSPECTION BY TE / <br /> FOR :•INSP.EGTION PRIOR TO GRO[7TING-AND.:FINAL. INSPECTION. r�J ,�•� - <br /> .5�731M <br />