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L SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> or.: F- USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?y�r'= k <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 Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sart Joaquin ocal Heath District. <br /> JOB ADDRESS/LOCATION 2 `� � 5 � CENSUS TRACT <br /> 'Owners Name -7'affA(S0Al Phone �� '�� _S . - <br /> _ <br /> Address zrr -N / WA� — .City G.oDl -e- 1 i- lF <br /> / / y <br /> Contractor's Name ( � License #.2"Z,(/ Phone4,! �� , °i <br /> TYPE OF WORK (Check) : NEW WELL -/ DEEPEN '/ /µPRECONDITION / / DESTRUCTION <br /> PUMP INSTLATION / PUMP REPAIR � PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK L SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ] <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private 4 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> � - Irrigation ,. Gravel Pack Depth of Grout .Seal <br /> Other' Rotary Type of Grout ' <br /> ii Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Types of Pump H.P. <br /> PUMP .REPLACEMENT: / / IState Work Done a <br />! <br /> PUMP, 'tEPAIR: <br /> State Work Done�. - -�x- <br />''� <br /> Approximate Be th <br /> DFgTRUCTION OF WELL: Well Diameter Pp <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californialpertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i <br /> after completion of my Mork'on a new well, I will furnish the San Joaquin Focal Health District 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 TITLE <br /> + ;4W PrOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> WPLICATION ACCEPTED .BY / .� DATE f`—x --77 <br /> " ADDITIONAL COMMENTS: <br /> PHASE II G T I SPjC {3N P SE II INA INSPECTION <br /> INSPECTION BY ATE INSPECTION BYDATE o <br /> CALL I.OR A GROUT IN PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _5/731M ' <br />