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c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. fli PICk USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP PERMIT Permit No. Z6���&) t <br /> THIS PERMIT EXPIRES .I 'YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit t0construct <br /> San <br /> uJ <br /> and/or install. the .work herein described. ' hisapplication <br /> ictionof tis made <br /> neJoaquin Lacalin Qfle�lthSDis�rictln <br /> County Ordinance No. .1862 and the RuRegulations <br /> .SOB ADDRESS/LOCATION A ESUS SUS <br /> Y cafie <br /> Owner's Name <br /> City , <br /> Address1111101 <br /> License17,6 <br /> honFlaiwContractor's Name <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/ / RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INST&LATION /, / PL`MP REPAIR / / PUMP REPLACEMENT I <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TAINK S PIT PRIVY <br /> SEWAGE DISPOSAL .FIELDWER LINECESSPOOL/SEEPAGE PIT OTHER <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavationor <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven. Gauge of Casing <br /> r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> { Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump -� <br /> PUMP REPLACEMENT: State Work Done I / <br /> S <br /> PUMP nPAIR: / 1 State Work Done , <br /> i <br /> # ,DF-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 F <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 /> TITLE �! <br /> SIGNED <br /> ' (DRAW PLOT PLAN ON REVERSE SI E) <br /> FOR DEPARTMENT USE ONLY p <br /> ' PHASE I DATE <br /> APPLICATIOI ACCEPTED .BY <br /> ADDITIONAL,-COMN1ENTS: <br /> P II GPt UT INSPE T ON PRASE III/FINAL INSPECTION <br /> INSPECTION BY ATE -' :- 7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> 5/731M <br /> 16- U ,x.19 <br />