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}� SAN JOAQUIN LOCAL HEAI"TH DISTRICT <br /> ` Stockton Calif. <br /> P0F_;OFFICE USE: 1601. E. Hazelton Ave: , i <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 tEAR FROM DATE ISSUED Date Issued 4 �3 <br /> (Complete In Triplicate) _2"b[- 120-o,4 <br /> Application is hereby spade to the San Joaquin Local Health District for a permit to cons <br /> 3ruct <br />" ancklor install :thecwork herein described. This <br /> application is made in compliance with San Joaquin <br /> County Ordinance Na. 1862 and the Rules and Regulations of .the San Joaquin Local Health District. <br /> c y p� <br /> d d1da� �ENSUS TRACT - <br /> SOB ADDRESS/LOCATION <br /> �- Phone <br /> Owner's Name <br /> City <br /> Address <br /> License # <br /> Contractor's dame <br /> TYPE OF WORK (Check): NEWjWELL / / DEEPEN '/_./ RECONDITION / / DESTRUCTION /? 41> <br /> 1 <br /> PUMP INSTALLATION / / PUMP REPAIR" ! PUMP REPLACEMENT /� <br /> SEWER LINES <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TY ` Dia. of Well Excavation <br /> Industrial Cable Tool <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information <br /> � Other �� . <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump ' <br /> PUMP REPLACEMENT: - , / I State Work Done <br /> PUMP REPAIR: State Work Done <br /> € Approximate Depth <br /> j ,DF.RTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health District <br /> 1 and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my wank on a new well, I will furnish the San Joaquin Local Health District <br /> DELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best k edge "belief.5 SIGNED W OT ERSE SIDE} <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE P <br /> f, APPLICATION ACCEPTED .BY I � <br /> 'ADDITIONAL COMMENTS: - p III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION ' W INSPECTION BY DATE . ?42— <br /> INSPECTION <br /> ..INSPECTION BY DATE <br /> CALL F'OR..A,GROUT INSPECTION PRIOR TO GROUTING AND-FINAL INSPECTION. 5/731 <br />