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FOR OFFICE USE: / SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 1601 E. Hazelton Ave.., StoQkton Calif. <br /> lif. <br /> APPLICATION FOR WELL CONSTRUCTION 6OR1PUMP PERMIT <br /> Permit No. <br /> ��G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <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. <br /> County�Ordinance .No. 1862..and the Rules andTh S Regulationstofnthe. San Joa uin L <br /> r made in compliance with San Joaquit <br /> Gf �W � w`� ac 1 Health District. <br /> JOB ADDRESS/LOCATION�� <br /> �: � q_tr{O �r7 <br /> Owner's Name- <br /> CENSUS TRACT <br /> Address <br /> Phone 1;9.yde 10L <br /> _ f <br /> Contractor's Name City <br /> 1LAd__ <br /> License # _s Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN _ <br /> PUMP INSTALLATION / / RECONDITION /7 DESTRUCTION /_7 <br /> Other <br /> / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> / / s <br /> i -- <br /> DISTANCE TO NEAREST: SEPTIC TANK ._ <br /> SEWER LINES r. PIT ,PRIVY <br />. SEWAGE DISPOSALL I'IELD � <br /> CESSPOOL/SEEPAGE PI-TIOTHER <br /> INTENDED USE TYPE ----- '' <br /> �. Industrial OP ELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool r <br /> _.�._ Domestic/private Dia• of Well Excavation <br /> Domestic _ Drilled Dia. of Well Casing i <br /> /public Driven <br /> _ Irrigation w Gauge of Casing <br /> Other Gravel Pack Depth of Grout Seal <br /> Rotary r ` . _ _.Type,.of,Grout <br /> Other <br /> ----�� Other Information <br /> t <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pu p <br /> PUMP REPLACEMENT: H.P. <br /> State Work Done <br /> PUMP REPAIR. State Work Done <br /> s <br /> ESTRUCTIQN OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby ------ <br /> Y , <br /> y agree to complwith all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FI <br /> after completion of my work on a new well, I will fu f <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use, FIFTEEN DAYS <br /> furnish the San Joaquin Local Health District a <br /> Lnformation i true t the best of my knowledge and belief. <br /> The above <br /> IGNED ;fir r <br /> (DRAW PLOT PLAN ON REVERS ETITLE <br /> SIDE <br /> HASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> /� <br /> PHASE II OUT INSPECTION <br /> vSPECTION BY DATE PRASE INAL INSPECTION <br />_ INSPECTION BY <br /> rL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ATE <br /> ;I 1426 <br />