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Cp <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT k` <br /> a <br /> FOF.X011ICE use: X601 E. Hazelton Ave. , Stockton, Calif. <br /> . 7 - Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _3y 3' P <br /> THIS-,PERMIT EXPIRES 1 YEAR-FROM DATE 'ISSUED -Date Issued X33 <br /> (Complete In Triplicate) ©0s, l CfT-7-j <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 Regulations of the San Joaquin Local Health District. <br /> e <br /> JOB ADDRESS/LOCATIONzz <br /> 1r d �d !CI" . CENSUS TRACT <br /> Owner's Name If SO Ai Phone <br /> Address 46 city , ygr*10"Aap <br /> Contractor's Name ,�".� _,_ License �ti. �id+s• hone ' <br /> TYPE OF WORK (Check): - NEW WELL DEEPEN -/—/ RECONDITION /_/ DESTRUCTION 17 � <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER_ LINES PIT PRIVY <br /> , . . � SEWAGE DrISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I Other Rotary Type of Grout. G' <br /> Other Other Information .rC-oaV°" O • <br /> � <br /> PUMP INSTALLATION: C,ontrac.tor / <br /> TY'pe cof Pump . H.P. <br /> PUMP REPLACEMENT: / / State Work.-.Done E `j <br /> PUMP. 'tEPAIR: / / State Werk Done ` <br /> ,pFgiRUCTION OF WELL: Well_Diatneter Approximate Depth . <br /> - - - <br /> Describe Material and-Procedure - - <br /> I he_reby3;agree to. comply with,'all laws and rdgulations of the San Joaquin Local Health District <br /> and the State of'C:alifornia 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 DRI ERS REPORT of `.the well and notify them before putting the well in use. The above <br /> inf6rma ion is ue to the -best of my knowledge and belief. <br /> Y <br /> SIGNED TITLE <br /> ( _ (DRAW PLOT PLAN ON REVERSE SIDE} <br /> "�"'°'• FOR DEPARTMENT USE ONLY <br /> I PtiASE I . <br /> APPLICATION ACCEPTED BY w lV� DATE <br /> ADDITIONAL COUNTS: <br /> " <br /> 'PHASE 14 GROUT 19SPECTION PHASE ,I L/FINAL INSPECTION �* <br /> INSPECTION BY - DATE INSPECTION BY DATE 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - __ _ 1,,1 5/731M <br />