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(���M a.,�--'�, Nrek-,A z� q sav- -�0��Y-C,-) <br /> S AQUIN LOCAL HEALTH DISTRICT <br /> F0 ;OP IC1; i3S1:: 1601 azelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLI TION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is here made to the San Joaquin Local Health District for a permit to construct <br /> and/or install t work herein described. ' This application is made in compliance with Sant Joaquin <br /> Count 'nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> OB ADDRESS/ OCATION <br /> Phone <br /> Own s Name <br /> oe l� City <br /> Address 1,L <br /> License # Phone <br /> Contractor's Name " <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN '/ lREPAIRI/N// PiIMPEREPLACEMENTSTRUCTION -/-T <br /> PUMP INSTAI.LATIti /!� PL`MP <br /> 00, <br /> Other /v! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRt1CTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavation <br /> kDrilled Dia. of Well Casing <br /> Domestic/private <br /> Domest3.c/public Driven Gauge of Casing <br /> i <br /> f Yrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I <br /> k PUMP INSTALLATION: Contractor t H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> -,PUMP ..'(EPAIR: State Work Done <br /> Approximate Depth <br /> pFgTRUCTION OF WELL: Well Diameter App �0 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the an 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 <br /> information is true to the best of my knowledge and belief. <br /> ' TITLE <br /> SIGNS <br /> (DRAW-PLOT PLAN ON REVERSE 5I E} <br /> • FOR DEPARTMENT USE ONLY <br /> PHASE I DATE --7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: r PHA E I IN AL INSPECTION <br /> PI'ASE�IGR�OUTINSPECTIOE INSPECTION BY DATE <br /> INSPECTION BY DATE _ <br /> 2 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> i 5/731M <br />