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F-7k <br /> ^ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Y 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> FOF-OlflCh USE: <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT - Permit No.T� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/a-2S`- +¢ <br />' (Complete in Triplicate) <br /> t ct <br /> Application is hereby made tl the San Joaquin Loccalic l alth nD strmade foinrcampliancetwi hnSanuJoaquin , <br /> and/ox install the work herein described. a <br /> T pPl <br /> County Ordinance No. 3852 and the„Rulea and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION O <br /> Phone <br /> Owner's Name Liv <br /> ` City ' ' <br /> Address � <br /> . Y LicensePhonewt6�.3 <br /> V.Contractor's Name <br /> TYPE OF WORK (Check") :- NEW WELL DEEPENI / �iPR�EPAIR�INDITON/, PUMPEREPLACEMENT�/- <br /> PUMP INSTALLATION / / PL <br /> Other I 1 <br /> PIT PRIVY <br /> DISTANCE TO NEARLST: SEPTIC TA;UK SEWER LINES OTHER <br /> j SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION_ SPECIFICATIONS <br /> Cable Tool - - 'Dia. of Well Excavation <br /> industrial Dia, of Well Casing <br /> Domestic/private Drilled V <br /> � Domestic/public Driven Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Other Information <br /> k -_ <br /> PUMP INSTALLATION: Contractor - <br /> HsP• � <br /> Type of Pump <br /> PUMP REPLACEMENT: /"' State Work bone <br /> PUMP "tEPAIR: /�/ State Work Done <br /> Approximate Depth <br /> ,DF-,TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> d re ulations of the San Joaquin Local Health District <br /> I hereby agree to comply with all laws an g Within <br /> and the State of California pertaining to or reguig hefurnisthecSan tJoaquin�Local Health District_: <br /> after completion of my work on a new well, I will - <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 /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ---------------- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE E II � DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL cololENTS: _ <br /> PRASE 11 GROUT INSPECTION PHASE III INAL INSPECTION <br /> _ _ 0- : 7 INSPECTION <br /> INSPECTION BY DATE E'Y f•.. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION. 5/.7lrl <br />