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g <br /> •►'* �/� -- SAN JOAQUIN LHEALTH DISTRICT <br /> FOF..OFFICE 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 -MIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquit. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` IV 5 'C�10Cr 5T CENSUS TRACT <br /> Owner's Name l S0/V Phone <br /> 4717 <br /> �1 �`Yl YC�-C,- _ <br /> Address 71 5-0 0 /1�� 4 Z City C'•�� <br /> Contractor's Name License # Phone '` <br /> TYPE OF WORK (Check) NEW WELL W DEEPEN _/ RECONDITION / / DESTRUCTION /__7 - <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEME <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK (Z SEWER LINES PIT PRIVY .� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 1HER fi p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC ,. IONS �J <br /> r 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 Type of Grout <br /> Other Other Information '- <br /> PUMP INSTALLATION: Contractor l�/C!-fI7a /SES � � <br /> Type of Pump i t'�Z j3iN� '- ��'/ af,! TliC.<saM H.P. <br /> PUMP REPLACEMENT• 4 <br /> State Wok none <br /> PUMP UPAIR: - / / State Worst Done <br /> ,DFsTRUCTION OF WELL: Well Diameter /�' j� • �� Approximate Depth <br /> E Describe Material and Procedure <br /> F <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 1 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL 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. <br /> • <br /> ! SIGNED OL TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ DATE / 71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT„I SPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />