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-�' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 11 Telephone: {.209} 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. N4- <br /> + F <br /> Date Issued 6-7 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED ---5� <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made to� the San. Joaquin Local Health District furca p rmit twit�►nSanu <br /> ppJoaquin � <br /> and/or install the work herein► described. ' This application is Ana <br /> County Ordinance No. 1.$62 and' the Rules and RegulaCions of the San Joaquin Local health S3iarrict. <br /> I <br /> JOB ADDRESS/LOCATION'. eta <br /> CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> City . . <br /> Address <br /> . DRILLING CO., SNC. '' <br /> License # Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check}: NEW WELL DEEPEN �/ RECONDITION /—/ DESTRUCTION 1-7 <br /> 1 <br /> PUMP INSTALLATION / I PUMP REPAIR ./ / PUMP REPLACEMENT l <br /> 4 Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE' DISPflSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �1 Cable Tool' Dia. of Well Excavation /Q �� <br /> Dia. of Well Casing <br /> Domestic/private . I Z----Drilled <br /> Gauge of Casing <br /> Domestic/public ``1 Driveng <br /> Irrigation Ii Gravel Pack Depth of Grout Seal <br /> - Other =1 L---Rotary <br /> Type of Grout <br /> -- - Other Information <br /> Other <br /> PUMP INSTALLATION: Contractor H. <br /> P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <br /> PUMP 'Z.EPAIR: / / .State Work Done <br /> Approximate Depth <br /> ,DF-,TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> a <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 _ urnish the San Joaquin Local Health District a <br /> { WELL DRILLERS REPORT of .the well and notify them before putting the well in use.. The above <br /> information is true to tho;best of my knowledge and belief. c� <br /> � SIGNED ��x' *ONERS <br /> I����/L� <br /> r +. (DRAW O E S DE)FOR DRt- MNLY <br /> PHASE I DATE JL <br /> !; APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: IONI . <br /> PHASE II GRO INSPECTION P S + I FINAL INSPECT <br /> INSPECTION BY <br /> DATE p�� INSPECTION- BY RATE <br /> --CALL-FOR A OUT, NSPECTION�-PRIOR TO GROUTING AND FINAL INSP <br /> ON... <br /> 57312 :f�� _-. <br /> -y — 1 Ile - - – - - - <br />