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T <br /> ri SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ,_. <br /> -'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-Z,?-37,;L- <br /> THIS <br /> o.-Z,?�� <br /> r THIS PERMIT. EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued -/S 7� <br /> (Complete In Triplicate) <br /> Application is' hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or in-stall 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 /> JOB ADDRESS/LOCATION �� . � CENSUS TRACT . <br /> Owner's Dame �"Ct L Scuet/N Phone -� � <br /> Address O [,[,mss ' L City � 3CiC dAl. <br /> Contractors Name f J ' _ _C�-�_r►®S.5 Z,2 ez �+J���'�t,, License ��r l hone <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN '/—/ RECONDITION / { DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR REPLACEMENT /7 � 't <br /> Other <�/ <br /> DISTANCE TO NEAREST: SEPTIC TANK /- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation X! <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other I - otary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor A, Gro <br /> Type of bump -` �T'� f- H.P. <br /> PUMP REPLACEMENT: /�/. State Work Done <br /> E <br /> PUMP, UPAIR: / 1 State Work Done <br /> •DFgTRUCTION 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 Distri t 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 Distrit 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 /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEYARTMENT.USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 1 <br /> ADDITIONAL COMMENTS: <br /> G UT INSPECTON F /F AL INSPECTION <br /> 44INSPECTION BY DATE � ,-� INSPECTION BY DATE <br /> CALL POP, Gk T INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. � <br /> E H 1426 5/731M <br />