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t <br /> ++-3s SAN JOAQUIN LOCAL HEALTH DISTRICT ---�`� <br /> J FO�E.:01-FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 q <br /> APPLICATION FOR WELL CONSTRY CT)ION,,AOR PUMP PERMIT Permit No. <br /> -- - r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $ �� <br /> (Compl&te fn 'Triplicprte-y <br /> Application. is hereby made to the San Joaquin Local Health DistricTt foir 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.,afld the{-Rules land Regulations of the San Joaquin Local health Disgric <br /> �3 also-_S_ �-�€..�•�.d�� J '` <br /> JOS ADDRESS/LOCATION �S/ G/t � I S82NSUS TRACT 2S5- zs0— <br /> iw� -- Phone J 72-- <br /> Owner's Name <br /> As <br /> S J �' /3 City <br /> ddres . <br /> i <br /> Contractor's Name - License # ID gZ--Phone - <br /> Aj <br /> TYPE OF WORK (Check) : �EW WELL-'/ V DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> MMP DAL <br /> 14STLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE^TO NEAREST: St�TIC TANK SEWER LINES PIT PRIVY <br /> S��AGE 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 <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Other Rotary- Type of Grout <br /> Other Other Information' <br /> I <br /> PUMP INSTALLATION: ContractorW- 5 1- c, r - `0 f S J O <br /> Type 'of=Pump a 116-,eS b L& H.P. <br /> PUMP REPLACEMENT: Sitate Work bone <br /> PUMPR: /% State Work Done <br /> •DF-,TRUCTION OF WELLWell Diameter Approximate Depth <br /> : <br /> Describe Material and Procedure <br /> I hereby"agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> C and the State'of California pertaining to or regulating well''construction. Within ..FIFTEEN DA) <br /> after completion £ my work e. The a on a new well, I will furnish the San 3oaquin Local Health above <br /> < <br /> o <br /> WELL DRILLERS REPORT of the we rind-onotify them before putting the well in usJ�PC <br /> information is true to th be of my ow edge- aii&Velief.. 12J <br /> SIGNED = TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION �XCEPTED,_BY _ DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE II / INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> T]-D-rr%u T11 PD(1i7TTTJC AMn VTNAT. TX.gPRCTT0N- <br />