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1 f <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT , <br /> rOor.:* F ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> 46. (Complete In Triplicate) 4 2- <br /> •2 fie ,../ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <br /> and/or install the work herein described. ' This <br /> egapplication <br /> made <br /> compliance <br /> Regulations ofthe SanJoaquinLocalHeal.thsan nis�ri�ct..n <br /> County Or 'nonce No. 1862 and the Rules and <br /> CENSUS TRACT <br /> JOB ADDRE LOCATI N <br />'FOwner's Name <br /> L Phone <br /> City <br /> Address - - --- -� —"�� <br /> -- - • ,[ . License ��,�� 6 Phon� <br />' Contractor's Name <br /> t <br /> TYPE OF WORK <Check): NEW WELL DEEPEN l�I RECONDITION I / DESTRUCTION l-T <br /> PUMP INSTALLATION / / PLMp REPAIR'./ / PUMP REPLACEMENT 1 <br /> Other <br /> k PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEI C POOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPO IELD � L/ — <br /> OF LL CONSTRUCTION SPECIFICA IONS <br /> / <br /> INTENDED USE TYPEIndustrial able Tool Dia. of Well Excavation <br /> -- `- 'estic/private Drilled Dia. of Well Casing � --- <br /> Driven Gauge of Casing <br /> Domestic/public <br /> �rigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> — Other _ Other Information <br /> 44. <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> f PUMP REPLACEMENT / / State Work Done <br /> PUMP "tEPAIR: / State Work Done <br /> Approximate Depth <br /> DFgTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 3 <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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District e <br /> 14ELL DRILLERS REPORT'of .the well and notify them before putting the well in use. The above <br /> information i true to the bes m knowledge and belief. <br /> TITLE <br /> 3 SIGNED <br /> (DRA LOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> &ll� <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS:: PHASE III/kINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 7 .fir <br /> INSPECTION BY DATE <br /> INSPECTION. <br /> . CALL FOR A GROUT%INSPECTION PRIOR TO GROUTING AND FINAL 51731M t <br />