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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> £OT'. OFF1cr, US]-,. : _ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 17"7- Dl' --t/ <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 Joaquin10caZ l-R!11 h District. <br /> .TOB ADDRESS/LOCATION ` ENS TRACT <br /> Owner's Name hone <br /> r <br /> Address City <br /> Contractor's NameLicense 4 ��Phon �Jj <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/J/ RECONDITION /—/ DESTRUCTION /? a <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I T <br /> Other / / m <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 <br /> Domestic/private Drilled Dia. of Well Casing <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 /> i <br /> PUMP INSTALLATION: Contractor, awdm, 2Aterx- , <br /> Type of Pump H.P. <br /> i (� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> DFIZTRUCTION 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 /> n 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 /> i <br /> SIGNED TITLE f?/1 <br /> (DRAW PLOT PLAN ON REVERSE SID-10 <br /> FOR DEPARTMENT USE ONLY <br /> 1 <br /> PHASE I <br /> APPLICATION ACCEPTED EVY DATE <br /> ADDITIONAL GOA�IENTS:� <br /> PHASEJI PROUT INaECTION 14qASE III/FINAL IN P CTI N <br /> INSPECTION BY DATE / INSPECTION BY DATE <br /> CALL FOR A GROUT iNSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> ! E H 1426 �731M -- -- <br />