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SAN JOAQUIN LOCAZ HEALTH DISTRICT ; <br /> F'OF.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S, p <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 Sant Joaquin <br /> County Ord Aance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONe� �T� J1l �J 1 rr / CENSUS TRACT <br /> Owner's Name I L � Phonea � <br /> Address d �,/-z CJ 1 _rj jEr ' . City L� �« � <br /> Contractor's Name �--/t} U M r>5 License Jjf4_; 37�honeW457Z:) i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION /`7 <br /> PUMP INSTALLATION / I PUMP REPAIR '/ I PUMP REPLACEMENT <br /> Other /_7 -- f►+ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C> <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 /> 40 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done J / <br /> PUMP REPAIR: / / State Work Done � <br /> .DF.�ZTRUCTION 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 /> .information is true to the best of my knowledge and belief. <br /> SIGNED _ }� Y-�,r ✓- _ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I 7 y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ItGVVt INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOP, A`'�GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. t <br /> r.. - , -,,If i. r:/7-4 <br />