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SAN JOAQUIN LOCAL HEALTH DISTRICT 0 <br /> 1601 E. Hazelton Ave. , -Stockton, <br /> FOR OFFICE USE: Calif. .. <br /> a Telephone:._ (209) 466-67$1 73 5 <br /> 7 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I=YEAR,FRON'DATE ISSUED <br /> Date Issued <br /> ! {Complete In Triplicate) <br /> isthereby,madeato+the: San,.Joaquin..Loca1 Health District <br /> inrco pliancea permit twithnSan Joaquin <br /> Application, plication' z <br /> and/or install the work herein described. This app <br /> County O -dinanc `FNo- - 1862..andt the.`Rules. and Regulations fof the San Joaquin Local Health District. <br /> aW <br /> CENSUS TRACT Lil <br /> JOB ADDRESS/LOCATION <br /> Phone I <br /> owner!9 Name' s <br /> City i <br /> Address �' � Q <br /> License # . Phone <br /> Contractors Nam <br /> A. <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN I UEPAIRCONDIT�INI/ PUMP EREPLACEMEN�I? <br /> PUMP INSTALLATION / / <br /> Other <br /> SEPTIC SEWER LINES OTHER <br /> DISTANCE TO NEARES SEWAGE DISPIT PRIVY POSAL FIELD CESSPOOL/SEEPAGE PIT <br /> E TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. 'of We11 Excavation --- <br /> Industrial —_X Dia, of Well Casing Y <br /> Domestic/private Drilled <br /> Domestic/public ubiic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Other i Rotary Type of Grout ` <br /> Other Other Information N <br /> - <br /> k � <br /> [ INSTALLATION: Contractor H.P. <br /> PUMP <br /> Typet of Pump <br /> PUMP REPLACEMENT: I / <br /> State Work Done <br /> PAIR: State Work Done_. <br /> PUMP RE - <br /> _ Approximate Depth <br /> ,DESTRUCTION OF WELL: Well <br /> Diameter , <br /> e al and Procedure r <br /> 4 k <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> EEN <br /> and the State of California pertaining to or willlfurnishwell <br /> theconstruction. <br /> LocalWithin <br /> Health District a <br /> after completion of my work a anew well, <br /> WELL DRILLERS REPORT of the wall and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge \-ad b lief. f <br /> ` TITLE <br /> SIGNED {DRAW PLOT PLAN ON REVERSE SIA <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I DATE — <br /> ' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS; PHASE III/FINAL INSPECTION <br /> PHASE II GROi3T INSPECTION INSPECTION BY DATE ,{�1 7 <br /> INSPECTION BY o? DAT$ • /-7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. _ 4/72Q_T ~ <br /> " E- H _1426 u <br />