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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "Or.TOFF ICE t€SL': 1601. E. Hazelton Ave. , Stockton, Calif. <br /> W� <br /> Telephone: (204) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0 <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> 1 (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 i� made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> fit' /t <br /> JOB ADARESS/LpCATION� CENSUS TRACT ' <br /> II/ - �� �� s � . <br /> _ r 4�4 <br /> Owner's Phono� bName I lr <br /> ,!. <br /> City <br /> Address y <br /> Cor tractor's Name / / /� /3 d d� License Phone <br /> IM <br /> TYPE OF WORK (Check) : NEW WELL 1n DEEPEN f 1 RECONDITION I I DESTRUCTION ! T <br /> PUMP INSTLATION / I PUMP REPAIR/ ] PUMP REPLACEMENT /� <br /> AL <br /> .+ Other 17 <br /> [ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED DISE TYPE 0 F.LL CONSTRUCTION .SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation O <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 /> 4. Other � � Other Information <br /> r� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work bone <br /> i <br /> PUMP 'R.EPAIR: / / State Work Done <br /> ,DF-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> fI 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 F <br /> WELL DRILLERS REPORT.),of .the well and notify thein before putting the well in use. The above <br /> j information is,true ito the best of my knowledge and belief. <br /> 4 TITLE <br /> SIGNED <br /> ��, RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> x PHASE I �� DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMrfENTS.,� <br /> PHASE II 0 I CTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY !i D E INSPECTION BY DATE <br /> .E <br /> CALL FOR A -GROUT.jINSPECTION PRIOR TO GROUTING.AND FINAL INSPECTION. � 5/?3 im <br /> R H 'LG25 1 _ - <br />