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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 3 7O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> 7,V- �44-41 <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued -21-,w�- <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 /> JOB ADDRESS/LOCATION 4Z,2 0 _ CENSUS TRACT <br /> Owner's Name ' : ,3 Phone <br /> Address Uu o-o A City ( <br /> zYContractor's Name L License �i ALU Phone •�d. <br /> TYPE OF WORK (Check): NEW WELL /� rDEEPEN / / RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION /� REPAIR / / PUMP REPLACEMENT /� <br /> Other /-7- <br /> VI—STANCE <br /> /DISTANCE TO NEAREST: SEPTIC TANK EWER DINES C f-PIT PRIVY <br /> SEWAGE DISPOSIL FIELD�� - CESSPOOL/SEEPAGE PIT& ,k OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <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 S al <br /> Other z, ito-tary Type of Grout' � c <br /> mow= Other Other Information _M1;•i2sm <br /> PUMP INSTALLATION:Contractor <br /> Type of Pump- . H.P. <br /> PUMP REPEACEMENT: / / State Work Done <br /> [ PUMP. REPAIR: , / / State Work Done - <br /> 1 .RESTRUCTION 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 acid notify them before putting the well in use. The above <br /> inform - on is true to t estknowledge and belief. <br /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEP-CCJL <br /> DEPARTMENT USE ONLY <br /> 3 PHA I <br /> " APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II OU P SE Ili FINAL INSPECTION <br /> INSPECTION BY DA - INSPECTION BY DATE -3 -1 _ <br /> CALL FOR A GROUT I EC N PRIOR TO GROUTING AND FINAL .INSP ION. <br /> E H 1426 � .4 / - 7172 1M <br />