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' SAN JOAQUIN LOCAL HEALTH DISTRICTQ <br /> IOr. Oti'1Ct: US1i: 1641 E. HazeltonVe. �"Stockton, Calif. <br /> -Telephone: (249) 466-6781 �� r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM Permit No. <br /> iW TA..� � <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE- ISSUED Date"NIssued ,Z 3 P�/_ <br /> (Complete In Triplicate) r J <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance,.No.,}1862 andithe Rules and Re ulations of the San Joaquin Local Health District. <br /> 74 <br /> .TOB ADDRESS CATION ® lc ' " / &CENS TRACT <br /> Owner's Name - • hone <br /> Address •' <br /> City <br /> Contractor's Name License # Phone <br /> 441 Oum <br />( TYPE OF WORK (Check) : NEW WELL . DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PLW REPAIR / / PUMP REPLACEMENT /_T <br /> Other % / V t <br /> DISTANCE TO NEAREST:, .,SEPTIC ,TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL t ," CONSTRUCTION SPECIFICATIONS <br /> Industrial . i = Cable Tool 'Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing f , <br /> Domestic/public w, ., I Driven Gauge of Casing <br /> Irrigation A Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout ; <br /> A Other s Other Information I <br /> 4 <br /> PUMP INSTALLATION: _, Contractor <br /> Type of Pump H.P. <br /> _ a <br /> PUMP REPLACEMENT: / / State Work Done" <br /> PUMP UPAIR: / ./ State Work Done , <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth ,f <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree to comply withiall 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 /> 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 t best of my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDEU— <br /> FOP, DEPARTMENT USE ONLY <br /> PUASE I <br /> APPLICATION ACCEPTED BY �+ DATE <br /> ADDITIONAL COK ENTS:Y <br /> PHASE II-GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE Z <br /> .; CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - .�:... 5/731M <br />