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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ffl�„OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: _(209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issue 7 <br /> /dam 2 3 <br /> (Complete In Triplicate) <br /> Application' is hereby made to the San Joaquin Local Health Distmaderict in prtwithnSai�nuJoaquin <br /> PP <br /> and/or insiall the work herein, described. This application is made n compliance <br /> County Ordinance No. 1$62 and the Rules and Regulations Of the San Joa in Local. Health District. <br /> . 6'a 5. ^} . CAN��.. CENSUS TRACT <br /> JOB ADDRESS/LOCATION ' <br /> Phone <br /> Owner's Name r <br /> a . City , <br /> ��� <br /> . i <br /> Address �. <br /> 7 <br /> Licensed <br /> Contractor's Name , y� hone i - +t'7fo <br /> TYPE OF WORK {Check) : NEW WELL/ / DEEPEN '/� RECONDITION / / DESTRUCTION f <br /> PUMP INSTALLATION / PUMP REPAIR'/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES PIT PRIVY (.7” i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> 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 /> Y <br /> Other Other Information ' <br /> PUMP INSTALLATION:' pontractor " <br /> I Tyge. of Pump H.P. `. <br /> r <br /> y PUMP REPLACEMENT: State Work Done <br /> p _ <br /> PUMP "REPAIR: State. Work Done <br /> ,pFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 /> 1 WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 1 information- is true .to-the best of my k w1 and belief. <br /> '� f-_• �. -TYLE <br /> SIGNED W POT PLAN ON R ERSE SIDE) <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY <br /> ' ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PRASE 11 GROUT INSPECTION DATE <br /> INSPECTION BY DATE - INSPECTION BY <br /> II3SPECTION. <br /> CALL FOR A-GROUT-INSPECTION PRIOR TO GROUTING AND FINAL <br /> 5/731M . <br />