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l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y U <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �S�OF.:OIFICL" l�S� Telephone: {209) 466-6781 <br /> __ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J <br /> l <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED <br /> (Complete• ln Triplicate) it <br /> Application is hereby made to the San Joaquin Localic l nalth Districtmae for <br /> perm <br /> ncetwathnSanud�aquan <br /> and/or install the work herein described. Ppl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> ,TOB ADDRESS/LOCATIONT <br /> Phone <br /> Owner's Name <br /> City U <br /> � Address <br /> License #` Phone " <br /> fContractor's Name <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN /_� RECONDITION J DESTRUCTION /_7 <br /> PUMP INSTALLATION J / PUMP REPAIR '/ / <br /> Other ,/ / <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINEPIT PRIVY CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> INTENDED 135E TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial - __ Cable Toole Dia, of Well Excavation <br /> Domestic/private � Drilled Dia. of Well Casing � <br /> Domestic/ <br /> p <br /> rival Driven Gauge of Casing <br /> Irrigation <br /> ublic <br /> Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor <br /> R.P. <br /> Type of Pump <br /> State Work Done { .M 7-AE PUMP REPLACEMENT: <br /> -. _._ <br /> G PUMP -tEPAIR: / / State Work Done <br /> C <br /> Approximate Depth <br /> DFATRUCTION OF WELL: Well Diameter <br /> _ <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of ll San Joaquin Luca] Health FIFTEEN <br /> DAYS <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wells I will furnish the San Joaquin Local Health District <br /> f 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-5el'ef• <br /> jj <br /> ITLE _ f <br /> ' SIGNED <br /> - f(DRAW PL 4N RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> i PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pS /FI AL INSPECTI <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE �2_4'P" <br /> INSPECTION BY - DATE <br /> 1 CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND.SINAI. INSPECT N. 5/731M <br />