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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOL OFFICE ` SL: 1601 E. Hazelton Ave. , Stockton,, Calif. <br /> Telephone: (209) d6--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,�77,_7-31 6 4�) <br /> THIS PERMIT EXPIRES l 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. 1862 and the Rules and Regulations of the Satz Joaquin Local. Health Dis4rict. <br /> JOB ADDRESS/LOCATION w L q A145 CENSUS TRACT <br /> Owner's Name �j� y � li��n �g/• Phone <br /> Address S S. 7�e"/Z-706 124 0% City 6 G�� rt�✓ <br /> Contractor's Name 1A A, License # Phone SSS O�O3 <br /> TYPE OF WORK (Check): NEW UIELL / DEEPEN / f RECONDITION j—/ DESTRUCTION /-7PUMP INS LATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE, TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD :L CESSPOOL/SEEPAGE PITA OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f� <br /> �2K _ 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 <br /> Other Othe Information <br /> i <br /> PUMP INSTALLATION: Contractor <br />" Type of Pump H.P. <br /> r PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DFcTRUCTION 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, a`nd notify thein before putting the well in use. The above <br /> information is tpm to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ^- <br /> ADDITIONAL COMMENT <br /> PT3A SPECTIONPHAS INSPECTI N <br /> INSPECTION BY TE p` INSPECTION BY DATE <br /> CALL FOR ► TI PRIG R UTTNG AND FINAL IN <br /> E H 1426 5/731M <br />