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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -P-Or.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k -- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z 1Qlc/ <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issded <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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' ; G CENSUS TRACT <br /> Owner's Nasse � _,`1. .-�� , ,... . Phone <br /> i <br /> Address City <br /> Contractor's Name License hon <br /> TYPE OF WORK (Check) : NEW WELL /f DEEPEN /_/: RECONDITION /_/ DESTRUCTION /_ <br /> PUMPIINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial i Cable Tool. Dia. of Well Excavation ` <br /> Domestic/private 1� ; Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge, of. Casing <br /> Irrigation I Gravel Pack Et Depth of Grout Seal <br />! Other 1 Rotary Type of Grout �o <br /> i Other Other Information <br /> PUMP INS`I2�LLATION: Contractor <br /> Type�4of Pump H.P. .. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP UPAIR: / / ,State Work Done ; <br /> DFIRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E I hereby agree to comply with all laws and regulations of the San JoaquinoLocal Health District <br /> and the State of California pertaining to or regulating well 'constructioA. Within FIFTEEN DAYS <br /> after completion of my. work on a new well, 1-will furnish the San Joaquin Local Health District a <br /> 1-7ELL DRILLERS REPORT of the well and notify therm before putting the well in use. The above <br /> information is true to the best of my knowledge.� and belief. <br /> I � A JJ <br /> SIGNED TITLE1 <br /> j (DRAW PLOT PLAN ON REVERSE SIDAAf <br /> a <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I 1 ����A��S �v-- .�s-�✓Q .Y✓f OrG^`"� <br /> o� a <br /> APPLICATION ACCEPTED BY DATE ��_ 1 •- .,�_ <br />` ADDITIONAL COMFENTS: 1 - <br /> PHASE II GftYft INSPECTION PHASE Irt/TI19AL INSPECTION- <br /> INSPECTION BY -- DATA INSPECTION BY DATE <br /> - CALL FOR A GROUT-INSPECTION='PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> E:H 1426 <br />