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-------------- <br /> FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> APPLICATION FOR WELL CONSTRUCTION 6OR1PUMp <br /> PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - . <br /> Application is hereby made t (Complete In Triplicate) Date Issued �( Lc7 3 <br /> the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 an'd the Rules andTRes Iationstofnthe San .7i <br />� made in compliance with San Joaquin <br /> JOB ADDRESS/LOCATION <br /> /9 quip Local Health District. <br /> Owner's Name i CENSUS TRACT <br /> Address P Phone If <br /> Contractor's Name City <br /> License # hone <br /> z <br /> TYPE OF WORK (Check).- NEW WELL /7 DEEPEN y� T <br /> PUMP INSTALLATION RECONDITION /_-7 DESTRUCTION <br /> Other / / /w/ PUMP REPAIR L/ PUMP REPLACEMENT /-7 <br /> DISTANCE TO NST: SEPTIC TANK 0 SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ---� <br /> Industrial _ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Domestic t.._ Cable Tool Dia. of Well. Excavation <br /> /private <br /> Domestic Drilled Di <br /> /Public a. of Well Casing -�� � <br /> 1. Driven <br /> Irrigation Gravel Pack Gauge of Casing <br /> Other Depth of Grout Seal <br /> _ Rotary Type of Grout �` ---- _ <br /> •►� Other Other In <br /> � <br /> c <br /> PUMP INSTALLATION: J <br /> Contractor <br /> Type of Pump r <br /> H.P. <br />'UMP REPLACEMENT: State Work Done <br />'UMP`^REPAIR.- �- --� /" StaeyW <br /> ork Done' T : <br />►ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San .Ioaquln Local Health Distri <br /> nd the State of California pertaining to or regulating well construction. ct <br /> fter completion of my work on a new well, I will furnish the San Joaquin LocalhHeal.thTDistrict a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. <br /> EGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> LASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> IDITIONAL COMMENTS: DATE <br /> %GR <br /> II ROUT INSPECTIO PHASE TIT FINAL INSPECTIO <br />'SPECTION BY DATE4 <br /> INSPECTION BY DATE t <br /> CALL FOR A <br /> IN <br /> PRT R _T GROUTING AND FINAL INS' C ON. <br /> E H 1426 <br /> - 7172 Im <br />