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y I�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Of..O1FICE SSE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a� 7� <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date issued <br /> - <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> And/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No., 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> ENSUS TRACT ' <br /> JOB ADDRESS')1LOCATION <br /> Phone �^ <br /> owner`s Name <br /> _ City <br /> Address P46= <br /> hon� <br /> Contractor's Name License <br /> 9 <br /> TYPE OF WORK (Check): NEW ALL DEEPEN /-7 RECONDITION DESTRUCTION DESTRUCTION - <br /> WE + <br /> PUMP INSTALLATION / / PUMP REPAIR'/ / PUMP REPLACEMENT 1 <br /> Other 1 I <br /> k DISTANCE TO NEAREST: SEP'T'IC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL./SEEPAGE PIT OTHER <br /> -------------- <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFI 'ATION5 <br /> k E Cable Tool Dia. of Well Excavation <br /> Industrial f <br /> } Drilled ilia. of Well. Casing `U <br /> Domestic/private --- Driven Gauge of Casing <br /> Domestic/public <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP TtEPAIR: I/ ' State Work Done <br /> ,DF-,TRUCTIO_N OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ll 'construction. Within FIFTEEN DAYS <br /> and the State of California pertaining to or regulating we <br /> after completion of my ;work on a new well, I will furnish 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 the best of my knowledge and belief. <br /> I TITLE <br /> SIGNED <br /> � (DRAW-PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> k <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P / INSPECTI N <br /> Pi iI OU INSPECTI INSPECTION B RATE <br /> INSPECTION BY E <br /> I <br /> w -ClLL-FOR ROUT-INSPE ON-PRIOR•TO GROUTING AND FINAL INS ' v �, 5/731M <br />