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F <br /> .� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k0 .'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR'PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1 /7�7 <br /> i <br /> , (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health District. <br /> County , <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> 61 Phone <br /> L Owner's Name <br /> City ' ' <br /> Address z f l <br /> License Phone?13 <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/ / RECONDITION / / DESTRUCTION 4 /-7 <br /> PUMP INSTALLATION I / PUMP REPAIR I 1 <br /> Other / <br /> ' IT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> CESSPOOL/SEEPAGE PIT OTHER \p <br /> SEWAGE DISPOSAL FIELD �} <br /> 1G INTENDED USE TYPE OF WELL CONSTRUCTION SJ?ECIFICATIONS t1`� <br /> Industrial Cable Tool <br /> Dia.. of Well Excavation <br /> �1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> i <br /> Domestic/public Driven Gauge of Casing <br /> Domestic/p <br /> _ Irrigation <br /> Gravel Pack Depth of Grout Sea3. �.�--- <br /> g Rotar Type of Grout, •, <br /> Other y <br /> � ��Other Other Information. . <br /> E <br /> PUMP INSTALLATION: Contractor H.P. ,- <br /> Type of Pump <br /> k <br /> t i UM' REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / .j State Work Done <br /> ' Approximate Depth <br /> DFCTRUCTION OF WELL: Well Diameter , <br /> Describe Material and Procedure <br /> with all Taws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply <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 <br /> Districts <br /> WELL DRILLERS REPORT of -.the. well and notify them before putting the well in use. The above ve <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> Ap3,ICATIoN ACCEPTED BY <br /> ADDITIONAL COI�NTS: P T FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE -0�5'1 <br /> DATE INSPECTION BY <br /> INSPECTION BY --- - ---- <br /> CALL FOR A..GROUT INSPECTION PRIOR -TO GROUTING AND FINAL INSPECTION. 5/731m, <br />