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^.SAN_ aAQUN LOCAL HEALTH DISTRICT <br /> USE: E. Hazelton Ave. 1 Stockton, Calif. <br /> k dor.-OFFICE USE: Telephone: (209) 466--6781 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� -�7�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> i Health <br /> ct <br /> Application is hereby made to the San Joaquin, Thisoa xli.cati n is made t <br /> made in compliaricewithnSanuJoaquiri <br /> and/or install the work herein described. <br /> PP <br /> . County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local kl.ealth District. <br /> r, '01 CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> /Z:)Phone �� <br /> owner's Name <br /> jCT ®� City . . <br /> Address /�i� O. � <br /> Licenser Phone S;;2-7 <br /> Contractor's Name <br /> k <br /> DEEPEN / / RECONDITION / I DESTRUCTION /7 <br /> REPLACEMENT / <br /> TYPE OF WORK (Check): NEW, WELL pLW RE AIR <br /> PUMP INSTALLATION L/ <br /> Other / S� <br /> EST: SEPTIC TANK/019SEWER LINES /,2AOPIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> DISTANCE TO NEAR ,� <br /> SEWAGE DISPOSAL FIELD/ lN�- � <br /> INTENDED U <br /> - CONSTRUCTION SPECIFICAT <br /> SE . TYPE OF WELLIONS y <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private ADriven Gauge of Casing <br /> _ Domestic/public ` <br /> Irrigation Gravel Pack Depth of Grout !n <br /> a Rotor y Type of Grout n _ <br /> Other Other '-Other,Information �;s;�r e, <br /> e <br /> PLUNF INSTALLATION; Contractor H.P. <br /> Type of Pump! <br /> +✓,tit �:` � <br /> PUMP REPLACEMENT: r!/ State WorktDone <br /> PUMP :'REPAIR: - / / <br /> State Work: Done <br /> i f <br /> � Approximate Depth <br /> i DF.CTRtICTION OF WELL: Wel].. Diameter <br /> Describe Material and Procedure <br /> a <br /> i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Within FIFTEEN AYS <br /> and the State of California pertaining`to or regulating we11 'canstruction. <br /> afterfcompletian of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of .the well. and notify <br /> them before putting the well in use. The above <br /> tbelief. y _ <br /> information is true to the best of my knowledge and <br /> SIGNED � " i <br /> TITLE . <br /> 4CDPL"OTP AN QN. REVERSE"SIDE) <br /> FOR DEPARTMENT.USE ONLY -•.� <br /> PHASE I <br /> ry� DATE <br /> APPLICATION ACCEPTED -BY C <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GR ` IU#� PHASE III/FINAL INSPECTION <br /> INSPECI <br /> .r' INSPECTION BY DATE <br /> 4 INSPECTION BY " DATE- <br /> CALL <br /> ATE-CALL FORA GROUT INSPECTION-PRIOR TO GROUTING AND -FINAL INSPECTION. 5/731M <br />