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V n <br /> SACT JOAQUIN LOCAL HEALTH DISTRICT <br /> Ar . <br /> F ICE USE: � .:1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Z 91110 <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�,7 /��3 <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION � - <br /> owner's Name � � __ Phone <br /> Address City . . <br /> Contractor's Name __ License #/l 1 3 7 3 Phone(- <br /> � <br /> TYPE OF WORK (check}: NEW WELL '/ / DEEPEN / / RECONDITIQN /�/ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT jW <br /> Other 4 I , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i PIT PRIVY <br /> SEWAGE ]DISPOSAL FIELD"". — i CESSPOOL/SEEPAGE PIT OTHER � <br /> INTENDED USE TYPE OF WELL # CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> .Industrial Cable Tool Dia.. of Well Excavation <br /> Domestic/private Drilled t Dia:, of Well Casing <br /> Domestic/public _.Driven"• 's. Gauge of Casing <br /> Irrigation - T 'Graver Pack "'""""'Depth-of-Grout -Seal <br /> j Other Rotary Type of Grout <br /> Other } ' Other Information <br />€ i � <br />'+ PUMP INSTALLATION: Contractor <br />' .. Type of Pump H.P. l L - <br /> } <br /> PUMP REPLACEMENT: �;'StateWork... 3one� + <br /> a PUMP YtEPAIR: / / State Work Done f: <br /> I <br /> pFSTRUCTION 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 /> F and the State of California pertaining to or regulati.ng,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 thews before putting the well in use. The above <br /> if information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW,?EOT_PLW ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i, APPLICATION ACCEPTED BY <br /> DATE /21 <br /> ADDITIONAL =M-NTS: _ <br /> PHASE If GR I E N PHASE III FINAL INSPECIMN . <br /> INSPECTION BY LAATE V INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 .5/731M <br />