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FOIL°OF ICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT p _ <br /> . Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby (Complete In Triplicate) Date Issued <br /> 4 y made to the San Joaquin Local Health District for a permit to <br /> construct <br /> and/or install the work herein described. <br /> County Ordinance ,No. This application is made in compliance with San Joaquii <br /> 182 and the Rules and Regulations of the San Joaquin, Local Health District. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name A a -)CENSUS TRACT <br /> Address Phone <br /> k <br /> Contractor's Name t City <br /> i � <br /> License ��/ p <br /> � �� gPhoneO <br /> p TYPE OF WORK (Check): NEW WELL <br /> �/ DEEPEN /-7 RECONDITION /_ <br /> PUMP INST CATION DESTRUCTION /"7 <br /> / PUMP REPAIR —/ / PUMP REPLACEMENT I-7 <br /> f Other / ,/ -� <br /> DISTANCE To NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIELDER FINES _. IT PRIVY <br /> CESSPOOL/SEEPAGE PIT <br /> INTENDED USE OTHER <br /> lndustrial TYPE DF WEL <br /> Cable Tool L ` <br /> CONSTRUCTION SPECIFICATIONS raw <br /> 1-Do /private gilled <br /> mestic Dia. of Well Excavation o <br /> DOmestic/public Dia. of Well Casing. <br /> Irriga'tion —_ __ Driven Gauge of Casing <br /> Other - �,." Gravel Pack Depth of Grout Sea- <br /> w rotary Type <br /> ype of Grout <br /> Other Information <br /> PUMP INSTALLATION: t0 <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P. <br /> State Work Done <br /> PUMP REPAIR: <br /> // State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth t <br /> ------ f <br /> I- <br /> hereby agree to comply with all laws <br /> n <br /> ad regulations of the San Joaquin Local <br /> ind the State of California pertainin <br /> 8 to yr regulating well construct <br /> if ter completion of my work an a new well, I will furnish the San Joaquin Local Health District a <br /> Health District. <br /> ion. Wifihin FIFTEEN DAYS <br /> TELL DRILLERS REPORT of the well and notify them before <br />.nformation is true to the best of my knowledge and belieftting the well in use. The above <br /> IGNED <br /> _ TITLE t <br /> (DRAW PLOT PLAN ON VEVE ER RSE SIDE i <br /> USE I FOR DEPARTMENT USE ONLY <br /> FPLC ION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> fSPECTION BY DATEPHASE ISI SINAL INSPECTION <br /> IN <br /> CALL FOR A GROUT INSPECTION PRIOR T0�ROUTINGDSPECTION BY DATE <br /> E H 1425 FINAL INSPECTION. <br /> k <br />