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® SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ..0 FFCE USE. 1601 E. Hazelton <br /> For-OFFICE Ave. , Stockton, <br /> Telephone:. (.209) 466 -6781 Permit No.ZZ=49 0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued lD - 73 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -----� -- <br /> (Complete. In Triplicate) rict permit to construct <br /> Application is hereby Made to the San Joaquin Local Health <br /> n Dist <br /> m de inrco pliance with San Joaquin <br /> i.nst.all the work herein described. ' This app Sa aquin Local Health District- <br /> and/or <br /> County Ordinance .Nv. 1862 and the Rules and Regu _0i Of 4 <br /> �f �' cENsus TRACT <br /> Jas ADDRESSILOCATION <br /> Phone <br /> Owner's Name <br /> . City ' <br /> Address I y / <br /> License #/ hone <br /> Contractor's_Name <br /> UCTION NEW WELL ! / DEEPEN '�/ RECONDITIa / / DESTRCEMENT�/7 <br /> TYPE OF WORK <br /> (Check) <br /> : <br /> PUMP INSTALLATION / PLTR' REPAIR / PSR' REP <br /> Other / / <br /> PIT PRIVY <br /> SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TAi3K CESSPOOL/SEEPAGE PIT OTHER,. <br /> SEWAGE DISPOSAL FIELD <br /> # INTENDED U5E TYPE OF WELL <br /> CONSTRUCTCATIONS <br /> ION 51'ECIFI <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 /> Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> --- Rotary Type of-Grout <br /> OtherOther Information ' <br /> � - Other <br /> t PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Dome <br /> u PUMP '�ExAIR� / . State Work Done <br /> Approximate Depth <br /> i DF-,TRUCTION OF WELL: <br /> Well Diameter — --- <br /> Describe Material and Procedure <br /> i} I hereby agree to comply with all laws todo e$elulatir►gtionsewelle`construction.San oilaijaIn L�Wi_thinaFIFTEEN tDAYS <br /> and the State of California pertaining S <br /> after comp letion.vf my work on anew welly I will furnish the San Joaquin Local Health District <br /> j. 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 knowle .ge an bels <br /> F <br /> ITLE <br /> j SIGNED ( PLOT PLAN ON T RSR SIDE} <br /> i FOR DEPARTMENT USE ONLY <br /> 1 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COM�TENTS: P I I/FI AL INSPECTIO <br /> PHASE II GROUT SPECTION INSPECTION BY DATE 3 <br /> V <br /> INSPECTION BY. DATE <br /> CALL..FOR A-GROUT- INSPECTION PRIOR TO GROUTING AND:.FINAL INSPECTIO 5/731M <br />