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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ; 1601 E. Hazelton Ave.'. -' Stockton, Calif . r d r <br /> 7 Telephone: - (209) 466-6781 Permit No.' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 1 <br /> THIS. PERMIT EXPIRES ,1 YEAR FROM DATE ISSUED Date <br /> Issued <br /> (Complete in Triplicate) <br /> to ct <br /> Health , <br /> rict <br /> ,a permit <br /> Application is hereby made to the San Joaquin Local icationDistmade inrco compliance with nSan�Joaquin <br /> and/or .install the work herein described. This app _ <br /> County Ordinance No, 1.$62 and the Rules and Regulations of the San Joaquin Local ,Health D, s.tr c <br /> Ga y <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION � <br /> � Phone <br /> Owner' s Name <br /> City <br /> Adress Phone <br /> License # <br /> Contractor's Name a <br /> k RCONI)IION_�/DESTRUCTION <br /> _ <br /> T <br /> _ - --= - DEEPEN_ / PUMP REPLACEMENT /�T <br /> `TYPE OF WORK (Check) :' pUFT INSTALLATION / / PUMP REPAIR / / <br /> Other <br /> SEWER LINEPIT PRIVY S OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK �^ CESSPOOL PIT <br /> PIT <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE I10MESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> IndustrialDia. of Well Casing C <br /> )< Domestic/p�rAi-vate �- Dolled <br /> 'ublic Driven Gauge of Casing <br /> Domestic/p Depth of Grout Seal <br /> Irrigation _ Gravel Pack P <br /> Rotary Type of Grout <br /> Cathodic Pjroteetion -- � Other Other Information <br /> Disposal It Surface Seal Installed B <br /> Geophysical <br /> pj _ INSTALLATION: Contractor — H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR. / tt� k`_.Done _.._,. <br /> I.. it Approximate Depth <br /> � DEST�tUCT ON OF WALL: Well Diames:,e <br /> escribe Mat rial and Procedure <br /> I he�«e agree to comply with ail laws and oregelulatingairicas owelleconstruc�ion,LoWithinaFIFTEENtDAYS <br /> and the State of California pertaining to $ <br /> saJoaquin Local Health <br /> w well, I willbefarfurn eputtingthewellinuse.. Theabove <br /> after completion of my woDistrict <br /> rk on a ne <br /> WELL DRILLERS REPORT of the well and notify t <br /> hem <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND INAL INSP CTION. TITLE <br /> MSIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE` <br /> F APPLICATION ACCEPTED BY — <br /> t, ADDITIONAL CO f PHASE III/FINAL INSPECTION <br /> P S I r6RO11 INSPECT N INSPECTION BY DATE <br /> .. INSPECTION BY DATE <br /> 077 2M <br /> l.IG <br />