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'el SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt. OFFICH' USL•': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUN? PERMIT Permit No. <br /> THIS PERMIT EXPIRES 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 Joaquin. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Ilealth District. <br /> JOB ADDRESS/LOCATIONs <br /> I"&&ICENSUS TRACT <br /> Owner's Name _! ( '� 9,6� Phone QO <br /> Addresscit <br /> SD �{ - <br /> y <br /> . O J gid .3-yea <br /> Contractor's Name License # Wil/ Phone <br /> r f <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN -/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /% R &WA2 24d(Aa,�`ac.f <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANKSE[JER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial _A Cable Tool Dia. of Well Excavation oll <br /> Domestic/private R Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of'Grout Seal <br /> I Other tRotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Fq <br /> Type of Pump A.P. <br /> PUMP REPLACE>MNZT: State Work Done <br /> ^_.PUMP_UP.AIR.:_,,, / / �-State 'Work:Done <br /> DF.gTRUCTION 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 and notify them before putting the well in use. The above <br /> i information is true to the best of my knowledge and belief. <br /> SIGNED I TITLE <br /> I RAW LOT PLAN ON REVERSE SIDE) C - <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMM NTS: <br /> PHASE II G P C PHA AIA/ INAL INSPECTION <br /> INSPECTION BY LAATE INSPECTION BY!y DATE <br /> _....CALL FOR A GROUT IN ECTION PRIOR •TO GROUTING AND FINAL INSPECTION. <br />