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/ R <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OT OFFICLI USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: .�,,(209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7j -33ze-) <br /> THIS.,PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) J� �� 7]_�3�/ <br /> Application is hereby rt to the. San' Joa uin ,Local Health District for e <br /> 4 �i� to construct <br /> and/or install the work .here describ_ed., a lication is made in compliance with San Joaquin <br /> County Ordinance 'Noe 3.862 an tie ulesaid R ulatia the San Joaquin Local Health District. <br /> YJ <br /> .TOB ADDRESS/LOCATIQN - CENSUS TRACT <br /> Owners Name P)V Phone <br /> 4 ` <br /> Address' Q/ :: _,.. City <br /> A <br /> Contractor's Name License 4jU=S/Phon� <br /> TYPE OF WORK (Check) : ., NEW WELL . . DEEPEN -/_/ RECONDITION /_% DESTRUCTION /_7 <br /> PUMP INSTALLATION J / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> ,, Other / <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 r <br /> Irrigation - Gravel" Pack Depth of Grout Seal Q a <br /> Other Rotary Type of Grout <br /> r Other Other Information ' <br /> PUMP INSTALLATION: t Contractor <br /> Type of Pump Kp. <br /> PUMP REPLACEMENT: :State Work Done <br /> PUMP 'tEPAIR: / J State Work Done <br /> DF-TRUCTION OF WELL ' Well blamer , . 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 & new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPQRT 'of 'the well and notify them before putting the well in use. The above <br /> information is ,true to the. best of m'y knowledge and belief. <br /> ! . <br /> i' SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> F• <br /> PHASE I <br /> I APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II OUT INSPECTIO PHAS i I/FINAL INSPECTION <br /> INSPECTION BY DATE' a INSPECTION BY DATE D <br /> CALL BOR,. ROUT-INSPECTION-P IOR..TO.GROUTING-AND _FINAL. INSPECTI <br /> cv <br /> e1/ �s 1 , q/7�i M �' <br />