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v SAN JOAQUIN LOCAL HEALTH DISTRICT ` i.E(O + <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 3 �.c7 �'`� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rule Vae=late` o of San Joaquin Local Health District. I <br /> JOB A59F <br /> dft/LOCATION - �r---/ — CENSUS TRACT <br /> Owner°s Name 1 Phone <br /> Address _ —� City <br /> Contractor's Name �' /7S f � Licensed ' Phone <br /> TYPE"QF WORK (Check) : NEW WELT. X DEEPEN ,/-7 <br /> -,.RECONDITION /—j DESTRUCTION <br /> PUMP INST LATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 5V, VLSEWER.LINES IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESgL/SEEPAGE PIT/ OTHER °'�r, t� <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing i/ V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation � ! <br /> g Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump H.P. <br /> _ f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> { <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District ! <br /> and the State �of California pertaining to or regulating well construction.. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above f <br /> information is tru to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> �(DRAW-PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I k <br /> 0 �/ f <br /> APPLICATION ACCEPTED BY DATE Q 3 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INITPECTION PHA4 . II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON, 4*�.2 <br /> E H 1426 F 7/72 1M I <br />