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R <br /> A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Stockton Calif. <br /> FOS'.:OFFILE U5L:. ]601 E. Hazelton Ave. , <br /> t Telephone: (209) 466-6781 � <br /> APPLICATION--FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> Date Issued (-.2..�= 7� <br /> ll (Complete In Triplicate) 2 -110. 12-- <br /> A <br /> Application is hereby rude to the San Joaquin Local Health District for a permit to construct <br /> Pp • This application is made in compliance with San Jbaquin .k <br /> and/or install the work herein described. <br /> andRegulatiars of the San Joaquin Loea1. H�alith District- <br /> County Ordinance No. 1862 and the. Rules <br /> l CQ,ZS +� 7�•v£ �4. . _ CENSUS TRACT <br /> .TOB ADDRESS/LOCATION _ <br /> Phone <br /> Owner's <br /> Name-74 N ' <br /> Address <br /> License # Phone -- <br /> T .Conte c�tor's Mame - <br /> TYPE O WORK (Check} : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT l- , <br /> 0 thele' / / <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: �] <br /> SEPTIC TANK SEWER LINES OTHER <br /> XSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT Z <br /> !TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool <br /> Dia. off f We11 Excavation o?o?•� <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Gravel Pack Depth of Grout Seal <br /> �i✓/� Irrigation . �_ Rotar Type of Grout <br /> Other y !1 <br /> Other Other Information <br /> C . . <br /> v TALLATION: Contactor <br /> PUMP I� S H.P <br /> Type of Pump <br /> IState Work DonePUMP RIJPLACE;`�ENT: �/ <br /> PUMP 'REPAIR: / IIIState Work Done <br /> Approximate Depth <br /> ,DFGTRUCTION OF WELL: Well. Diameter <br /> qtr _ <br /> Des6ribe Material and Procedure <br /> I hereby agree to comply witTi all laws and regulations of the San Joaquin LocHealth District <br /> al <br /> the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> and <br /> after completion of my work on a new well, I will -furnish the 'San Joaquin Focal Health District a <br /> I WELL DRILLERS REPORT of .the. well and notify them before putting the well in use. The above <br /> i information is true to th6'best of my knowledge and belief. <br /> TITLE <br /> SIGNED (wo PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL- COMYX-NTS: <br /> PRASE II GROUT INSPECTION p S I NAL DATE ON <br /> INSPECTION BY -�-- <br /> DATE INSPECT DATE <br /> 4 - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />