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f _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FDF' -O 'FICL 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 Issued :!Z- <br /> (Complete <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..- 18 d the Rules and Regulations _of the San Joaquin Local Health District. <br /> r f'L7 !�" /�-�/ G` <br /> JOB ADDRESS/LOCATION, CENSUS TRACT <br /> Owner's <br /> Owner`s eName (� ,. s !Q ! r Phone J �U <br /> City , 7-1 a rV14 <br /> Address <br /> Contractor's Name <br /> l O I License a�d one �l <br /> j ��/RECONDITION / / DESTRUCTION /� <br /> E TYPE OF WORK (Check) : NEW WELL -f—// / DEEPEN /!/1 REPLACEMENT /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP _ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DZSPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL oQ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation _ -- Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ! PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / <br /> State Work Done , <br /> DF�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> r 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 gest gif m knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> z PHASE I <br /> DATE <br /> APPLICATION ACCEPTED .BYA <br /> ADDITIONAL =01ENTS: <br /> NSPECTIOSIIFINAL INSPECTION <br /> PHASE II GROUT N <br /> INSPECTION BY DATE INSPECTION BY DATE �— <br /> �� ,-CALL I'OR A-GROUTfiNSPECTION-PRIOR TO GROUTING AND FINAL TNSPECTI <br /> I, 17 11.176 - 5/731M <br />