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IF <br /> J ✓3``�L y"�'I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1,O <br /> F,:OIFICE EUS : 1601 E. Hazelton Ave. , Stockton Calif. <br /> L-_:2_.- 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 /> I- - (Complete In Triplicate) <br /> Appi .tation 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 Ido;- I862 .azd the Rules and Regulations of the San Joaquin Local Health D'isprict. <br /> JOB ADDRESS/LOCATION 07 1P <br /> A0Viff_4V __ 0 CENSUS TRACT - <br /> . 'Owner's <br /> RACT - <br /> ._Owner's Name , <br /> Phone <br /> Address h VY City <br /> Contractor's Name !/f `; <br /> License �� Phone " Z •� (,?G <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN I`I RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT 4- <br /> Other I l <br /> DISTANCE TO NEAREST: SEPTIC-tTANK ,. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` U <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 ,� .. e.of <br /> TYP -Grout _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT <br /> State Work bone B a <br /> PUMP 'tEPAIR: State Work Done <br /> ;DFgTRUCTION 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 E <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 an lief. <br /> SIGNED <br /> ` DRA PL LAN ON -REV SE SIDE) <br /> DEPARTMENTU <br /> PHASE I SE ONLY <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COUNTS: <br /> PHASE II/GROUT INSPECTION PHASE III/FINAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> i4 <br /> CALL FORA GROUItINSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. „�.. <br /> E H-;1426 %°• 'k m. <br /> _ e <br />