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_ SAN JOA UIN LOCAL HEALTH DISTRICT <br /> �OFFIC8 USE:~ 1601 E. Hazelton Ave. , Stockton, Calif. �` � field-4 /P <br /> Telephoner {209} 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No>. <br /> { <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 Heals istrict made furca permit to consti.uh San Joaquin <br /> and/or install. the-.w0rk'herein described. This application <br /> County Ordinance No.,1862 and the.Rules and Regulations Of the San Joaquin Local health District. <br /> t <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION . . g <br /> Phone <br /> Owner's Name <br /> r _ City <br /> Address ' <br /> ti License #.7DO LVPhone <br /> Contractor'- Name. <br /> I <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '�W RECONDITION I l DESTRUCTION — <br />;. <br /> PUMP INSTALLATION / PLW REPAIR / / PUMP REPLACEMENT 17 <br /> k Other <br /> DIIlk <br /> STANCE TO NEAREST: SEPTIC TALK SEWER LINES PTT PRIVY <br /> SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E <br /> NIJ <br /> .INTENDED USE TYPE OF WELL. <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool' Dia. of Well Excavation <br /> Drilled 4 Dia. of- Well Casing <br /> ! Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> r Type of Pump <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP 'tEPAIR: - / ./ State Work Done ` <br /> ,DF��TRUCTION OF WE Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure. <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 /> iafter 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 <br /> information -is- true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SID ) <br /> i OR DEPARTMENT USE ONLY <br /> PHASE I DATE _ <br /> APPLICATION ACCEPTED BY ' <br /> ' ADDITIONAL:_ COMMENTS: PHASE IIT/FINAL INSPECTION <br /> PHASE II T - EC ON INSPECTION BY ATE <br /> INSPECTIOI3 BY DTE <br /> CALL FOR A-GROUT,.INSPECTION.-PRIOR TO GROUTTiiG�ANp FINAL INSPECTION. 5/731M . <br />