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SAN JOAQUIN LOCAL HEALTH DISTRICT 7;-L/ <br /> FOF...OFFICEUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 a <br /> '�,f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �r1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,22 / <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 Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION SG,S S' lt>o,,�Or-+,� ,, /�, CENSUS TRACT <br /> Owner's Name r ��r c� S All e A Phone <br /> Address City 74Ce. N <br /> ^, � � <br /> Contractor's jName License Phone��z ��o„cs �[%P f.0 /�r�����.v[. <br /> TYPE OF WORK (Check) : NEW WELL/.__ DEEPEN/-7 RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /LREPAIR / / PUMP REPLACEMENT -7 <br /> Other <br /> .DISTANCE TO NEAREST:. SEPTIC TANK ,222ZZ! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL s CONSTRUCTION SPECIFICATIONS <br /> Industrial t ,Z_,-C�ble Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ` } Domestic/public Driven Gauge of Casing <br /> :L,�--Trrigation E Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP. INSTALLATION: Contractor F't'�° �cpS.s W�� �.�i«< .-4� e , <br /> f Type of Pump H.P. ,2O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP,'ZEPAIR: Y f„ / / State Work Done <br /> .DF.qTRUCTION-OF WELL: `Well Diameter T- -- --" Approximate-Depth----~--- <br /> Describe Material and\,Proce.dure,' <br /> I hereby agree to comply with all lavas -afnd regulations of the San Joaquin Local Health Districl <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAY: <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The abov <br /> .f <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE f > , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> < / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I�II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D,E <br /> /�irti <br />