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4 <br /> SAN JOA4 UIN LOCAL HEALTH DISTRICT"" <br /> FOS. OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> '� <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE "ISSUED Date Issued <br /> (Complete in Triplicate) <br /> Application is hereby made ti District <br /> the San Joaquin�$ocalHea th ismade inrcompliance a permit twithconstruct San Joaquin ' <br /> and/or install the:work herein described. PPl <br /> Ordinance No:: 1862 anA the Rules and Regu3atiana of the San Joaquin Local }te��]th DisCrict. 4 <br /> County I t <br /> CENSUS TRACT " <br /> JOB ADDRESS/LOCATION <br /> Phone 4 <br /> i <br /> Owner's Name <br /> ;{ c City ' ' <br /> Address <br /> License hone- <br /> � � <br /> Contractor's Name <br /> t <br /> TYPE OF WORK (Check) : NEW td8 "ICU DEEPEN PUMP REPAIRECONDIR/N / pUMPEREPLACEMENTSTRUCTION ___ 1_7 <br /> PUMP INSTALLATION / <br /> t <br /> Otherr / <br /> PIS" <br /> DISTANCE TO NEAREST: SEPTIC TANK24 <br /> _ SEWER LINES OTHER" <br /> SEWAGE DISPOSAL FIELD C SSPO L/SEEPAGE PIT <br /> INTENDED USE I TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private t`�Driven Drilled Dia. of Well Casing <br /> ` Gauge of Casing <br /> Domestic/public y <br /> Irrigation Gravel Pack Depth of Grout Seal lJ ' <br /> Rotary Type of Grout <br /> Other ,�Other Other Information <br /> � r ' �- <br /> PULMP INSTALLATION: Contractor Z <br /> Type of Pu p <br /> PUMP REPLACEMENT: I <br /> State Work Dome <br /> PUMP TtEPAIR• / State Work Done <br /> : � Approximate Depth <br /> DF-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> } I hereby agree 'to comply with all laws and regulationsof the San Joaquin Local Health District <br /> # and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> �i1 furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, I wa <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 /> j E TITLE <br /> SIGNED <br /> SIRE <br /> (DRAW PLOT PLAN ON REVERSE <br /> a FOR DE TMENT USE ONLY <br /> i <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pHAS II FIN INSPECTICJN <br /> i P II Q T DNSPECTIfl INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FO ROUT INSPECTION PRIOR <br /> FINAL IN5 TION. 5/731M <br />