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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POI. OK ICE USE: 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 Issuedi- 7� <br /> (Complete In Triplicate) <br /> Application is hereby rude 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 Satz Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name PhonejaVto __ <br /> Address <br /> City . . <br /> - i <br /> 4 <br /> Contractor's YName (//��• _ LicensePhone �� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/—/ RECONDITION I f DESTRUCTION /`7" <br /> PUMP INSTALLATION �K4 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWED LINES PIT PRIVY <br /> �* SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> �4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateXDrilled, r Dia. of Well Casing of <br /> Domestic/public ___ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other yr Rotary Type of Grout , <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumppp U'1,P1� H.P. ' <br /> PUMP REPLACEMENT: / j State Work Bone `4 <br /> PUMP 'REPAIR: / j State Work Done i <br /> .BFRTRUCTION 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 true to the best of my knowledge and belief. -f <br /> SIGNER TITLE <br /> (DRAW-11P PLOT PLAN ON REVERSE SIDE)PHASE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION , <br /> PPLI I <br /> ACATION ACCEPTED .BY DATE � <br /> ADDITIONAL COMMENTS: <br /> PHA,91 IWROUT INSPECTI N PHASE 4,gi INAL IDISPECTION <br /> INSPECTION B DATE INSPECTIONBY E z- , - <br /> CALL FOR G OUT INSPECTION PRIPOR TO GROUTING AND FINAL INSPECTION. y <br /> E H 1426 -- t`` 5/731M" r <br />