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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> To—r..OIFI E USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby made to- 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 /> County Ordinance No., 1.862 and' the Rules and R tions of the San Joaquin ealth District. <br /> JOB ADDRESS/LOCATION RACT <br /> Owner's Name cd d �C.fi Phone <br /> Address �.�. a �- city . <br /> Contractor's Name � W e.��- License #/ phone y 7,4 <br /> TYPE OF WORK (Check): NEW WE J / DEEPEN -/ T RECONDITION / / DESTRUCTION IrT <br /> PUMP INSTALLATION / PUMP REPAIR .Zg PUMP REPLACEMENT <br /> Otherl/ / <br /> DISTANCE TO NEAREST: SEPTIC ".TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing ' <br /> _ x Irrigation y Gravel Pack Depth of Grout 'Seal <br /> Other `. -1 Rotary Type of Grout <br /> r Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump k. !H-.P. moo: <br /> PUMF REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: /. State Work Done 15Z <br /> ,DFQTRUCTION OF WELL:' Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> I hereby agree to "comply with all Laws and regulations of the San Joaquin Local Health District i <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 a <br /> WELL DRILLERS RLPORT 'bf the ;aell.and notify them before putting the well in use. The above <br /> informnlif <br /> s true to .the best of my . w1 ge and elief. <br /> SIGNEDkJuc•- -TLE <br /> ( L LOT PLAN ON RE RSE SIDE) <br /> tl <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY - DATE S� /� <br /> ADDITIONAL COMMENTS jl <br /> PIIASE' II GROUT JNSPECTION PHA I/FINAL INSPECTION <br /> INSPECTION BY 6,DAT'E INSPECTION BY DATE <br /> ,CALL-FOlt.A.,GROUT--INSPECTION-PRIOR -TO-GROUTING AND FINAL. INSPECTION. . <br /> F �L�� 5/731M <br />