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r .� <br /> S'JOAQUIN LOCAL HEALTH DISTRICT <br /> s' QR OFFICE USE: 1601• Horeltcn Ave., Stockton, Calif. <br /> Telephorne t (209) 466-6781 fi <br /> APPLICATION FOR WELL CONSTRUCTION OR PU12 PERDUQMPRO). /- <br /> THIS PERplIT. EXPIRES 1 YEAR FRO'!! DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a persit to . �ysttuct <br /> and/or install the work herein described. This application is made in compliants with Sate Joaquint <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local,Health AistrIct.: <br /> JOB ADDRESS/U3CATION CENSUS TRACY <br /> � <br />} Ort <br /> wr.r'a Name i'h `� <br /> one -1��4 _ <br /> k Address XZZ City ,= <br /> Contractor's Name A License ! Phonecm I ► <br /> z <br /> aLIF <br /> r.. TYPE OF WORK (Check): NEW WELL /? DEEPEN 7 RECONDITION /7 DESTRUCTION /7 <br /> o-, PUKP INSTALLATION PUMP REPAIR /-7—pump REPLAcemi Il <br /> Other / <br /> k, . <br /> E., DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE'OF WNEIV CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ° <br /> ' - Domestic/public Driven Gauge of Geeing <br /> Irrigation Gravel Pack Depth of Grout Seal '. <br /> Other Rotary Type of Grout R ` <br /> Other Other Information ,; <br /> ,a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . ; H.P. 5�: <br /> fay- .Fjq O- <br /> �.NT <br /> ' <br /> PUMP REPLAC : � State Work Done � e, <br /> 1�� <br /> PUMP REPAIR: /7 State Work Done <br /> dt <br /> s} ,pESTRUGTION OF WELL: Well Diameter Approximate Depth <br /> I 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 /> ' <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 thew before putting the veil in use The above <br /> information is t to the beet of my knowledge and belief. <br /> SIGNED own ' TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY n <br /> PHASE I <br /> << APPLICATION ACCEPTED BY .—.DATE <br /> ' ADDITIONAL COMMITS: . <br /> PHASE II.GROUT INSPECTIONPHASE iII .FINAL.IMSPECTION <br /> INSPE{.TION EY DATE INSPECTION BY DATE y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 9 K 1426 2 ' <br /> ,r. <br />