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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ---`-' 1601 E. Hazelton Ave. , Stockton, Calif, <br /> FOF':OIFICE USE: Telephone: (209) 466-6781 -71-*IV <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPI!ES 1 <br /> YEAR FROM DATE ISSUED Date Issued. <br /> � I <br /> I (Complete In Triplicate) ermit <br /> ct <br /> Application is hereby made to the San Joaquin Local Health District ract iorcompliancetw thnSa7u3 aqu x� <br /> and/or i� application is <br /> and/or install the work herein described. ' This app <br /> Count Ordinance No, 1$62 and the Rules and Regulations of the San Joaquin Local health District. <br /> County j)q 2v ( - ,t- ,CENSUS TRACT �- �- <br /> JOB ADDLOCATION <br /> RESSI <br /> +-� Phone <br /> Owner's Name <br /> City <br /> 11 <br /> Address z <br /> License PhoneT,7 - { <br /> Contractor's Dame <br />` Check); NEW WELL -/77' DEEPEN '`/ / RECONDITION l / DESTRUCTION /_7 <br /> TYPE OF WORK ( PUMP INSTALLATION I I pLW REPAIR / / PUMP REPLACEMENT I,T <br /> Other / 1 <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEARESSEWAGE DISPOSAL FIELD <br /> T: SEPTIC WANK CESSPOOL/SEEPAGE PIT OTHER _ <br /> 37` TYPE OF WELL CONSTRUCTION SPECIFIGATIONS <br /> INTENDED USE Gable Tool Dia. of Well Excavation <br /> Industrial -��" Drilled Dia. of Well Casing 62 ` <br /> -Domestic/private `----- Driven Gauge of Casing <br /> Domestic/public <br /> � Gravel Paoli Depth of Grout $eal <br /> Irrigation Rotar Type of Grout <br /> Other y <br /> -- �. Other Other Information <br /> s <br /> k PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> �PtiMP=`tEPAIR..,�,�::.: �---�-�-/'�'•"'°,S'�te�T'1c�rk"Do�"�"".�.'. <br /> x Approximate Depth <br /> DF.TRUCTION OF WELL:`. Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to Comply <br /> Gritti' all laws and regulations of the an <br /> Joaquin Local Health District <br /> I AYS <br /> and the State of California pertaining to or willegulfurn hating ethec5antJoaquin.LocalhHealth Distin FIFTEEN rict <br /> I after completion of my work on a new wren, <br /> I WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> ¢ TITLE <br /> } <br /> SIGNEDW PLO PLAN ON REV SE SIDE) <br /> t' FI} DE NT USE ONLY (� <br /> y. DATE <br /> PHASE I <br /> APPLICATION ACCEPT, <br /> ADDITIONAL CO /IS S /IFINAL INSPECTION. 1 <br /> SE GROUT INSPEC ON INSPEGTTON- DATE 7 <br /> INSPECTIO DATE <br /> p <br /> .- . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731X <br /> /731M <br />