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P <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F i 01"ICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e-7-23 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D j O // �_ CENSUS TRACT <br /> Owner's Name /�l�i�f r ���� Phone <br /> Address r � ��, �:. city . <br /> Contractor's Name ��r i License # Phone��k <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / j RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /—/ PLW REPAIR / / PUMP REPLACEMENT /-7 <br /> Other 57 <br /> ...._.. !1'b a� <br /> DISTANCE TO NEAREST: SEPTIC TkNK Z/� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing O <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: Cont actor 1106-If <br /> Type of Pump s �c���� �s� H.P. _.f <br /> PUMP REPLACEMENT: / / State Work''Done <br /> PUMP UPAIR: J j State Work Done <br /> DF�TRUCTION 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 <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 REPORT of the well and notify them before putting the well in use. The above <br /> information is tr to the best of my knowledge and belief. <br /> SIGNED ��.��- ` � -%'� TITLE <br /> (D PLOT PLAN ON REVERSE SIDS) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENT <br /> P S P dINAL INSP CTT <br /> INSPECTION BY ATE INSPECTION BY /_ DAT <br /> CALL FOR AG PECTION"P O 0 G OUTING AND FINAL INS G IoW <br /> - E_ H 1426 _ _ - ✓/ V 5/733M <br />