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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF LHSL <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _--`� r <br /> (Complete In Triplicate) /Z(j--tea v <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const�r,uct <br /> and/or install the work herein described. " This application is made in compliance with San Jaaquini <br /> County_Ordinance Na.- 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> L14l2:5- +� � �'�`Y , CENSUS TRACT ' <br /> .TOB ADDRESS/LOCATION } � <br /> EZ-V <br /> Phone - -- <br /> owner's Name <br /> I City <br /> Address. <br /> License _ Phone ' <br /> Contractor's Name - <br /> RUCTION <br /> TYPE OF WORK (Check) : NEW WELL AL/ / DEEPEN/ / . RECONDITION // PUMP/ D REPLACEMENT/� 1 <br /> PUMP'TNSTLATION I PUMP REPAIR <br /> 0then' <br /> DISTANCE TO NEAREST: SEPTIC TA�iK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled - Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other A Rotary Type of Grout <br /> Other _ Other Information r <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / /' State Work Done <br /> PUMP REPAIR: State Work Done <br /> pFITRUCTION OF WELL: Well Diameter <br /> Approximate Depth _ <br /> Describe Material and Procedure <br /> i <br /> s of the San Joaquin Local Health District <br /> I hereby agree to comply with all laws and regulation <br /> well `construction. Within FIFTEEN DAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work an a new well, I will -furnish the San Joaquin Local Health District � <br /> C,rELL 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 /> � <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 7 FOR DEPARTMENT USE ONLY <br /> i PHASE I DATE <br /> APT'T;ICATION ACCEPTED BY <br /> ADDITIONAL CO-I%SMENTS.: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE .---/`z` �� <br /> INSPECTION BY DATE ;10A <br /> CALL FOR A-,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. .5/731M <br />