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+� � 4 <br /> L.. SAtr - <br /> :TOAQUIN LOCAL HEALTH DISTRICT <br /> F. 0 FF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit- No. <br /> ,-3._-_3 D-3 CJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dare ISSucd <br /> (Complete In Triplicate) <br /> lication is hereby raade to the San Joaquin Local Health District for a permit to coit:.;e.j-uc.t <br />/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> aty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Iieolth District. <br /> ADDRESS/LOCATION <br /> CENSUS TRACT L14 <br />.r's Name Phone - c <br />-ess �� t <br /> City <br />:ractor`s Name License '//R,3 Z Phone --�3 <br /> OF WORK, (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> OtherAS <br />'ANCE TO NEAREST: SEPTIC TANK,;4_t, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS `V <br /> Industrial4-- Cable Tool Dia. of Well Excavation <br />�-mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout g �� <br /> Other Other Information <br /> INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. - <br /> REPLACEMENT: I / State Work Done <br /> rtI;PAIR: State Work Done <br /> RUCTION OF WELL: Well Diameter j <br /> Describe Material Approximate Depth and Procedure - <br /> rcby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />-he State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> completion of my work on a new well, I will furnish the San Joaquin Local Health District a' <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />'mation is true to the best of my knowledge and belief. <br />;D <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> I ` FOR DEPARTMENT USE ONLY <br />.CATION ACCEPTED BY DATE ' -.;2 '"�7%3 <br />'ZONAL COiNfiiENTS: <br /> PHASE Tx GROUT INSPECTION . PHASE III/FINAL INSPECTION <br />=ION BY f�- DATE r� � � INSPECTION BY % _ DATE <br />.LL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL TNSPFCmrnu-.• � � F <br />