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AISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FflF. Oik---TC gL. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 166-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -� <br /> T i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for amp rmi cetwithaSan construct <br /> PP <br /> and/or install the work hexein .described. ' This application is made n c p <br /> County OrdinaAcle No 862 and the Rules and Regulations of the San Joaquin Local ilex .th District. <br /> A,3 CENSUS TRACT ' <br /> JOB ADDREZLOCAT i <br /> Phone <br /> Owner's Name 11 <br /> y City '_ <br /> f Address <br /> ? _ License. Y � �Phone <br />/ Contractor's Name <br /> E OF WORK (Check): NEW WELL / DEEPEN _7 RECONDITION DESTRUCTION <br /> DESTRUCTION I T <br /> TYP PUMP INSTALLATION / PUW REPAIR / / PUMP REPLACEMENT /7O Cher / / —, ', t_ � 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK= SEWER LINESPIT PRIVY1 <br /> SEWAGE 'DISPO AL FIELD <br /> q;a. _ 7/50 <br /> SPOOL/SEEPAGE PIT OTHER ' `{ <br /> CONSTRUCT <br /> SPECIFICATIONS <br /> INTENDED USE [TYPE OF -;WELL %_. <br /> Industrial. .-t...�.. . ' .Cable Tool ''"Dig. of Well Excavation <br /> _ __Damcstic./:Privateer Drilled Dia..:of.. Well,.Casing-. v 1 <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of .Grout Sea <br /> Other Rotary >� TyWof Grout x <br /> Other 0tfi frritifformation <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump r_ - x.P. ' r <br /> PUMP REPLACEMENT: /. / State Work Done <br /> PUMP "tEPAIR: State WorkDone <br /> f <br /> ;DF-,TRUCTION OF WELL: Well Diameter <br /> f 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 /> and the State of California pertaining to or regulati.:ig well''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will -furnish the San Joaquin Local Health District a <br /> WELL DRILLERS qPORT of .the w 1 and notify them before putting the well in use. The above <br /> information 's rue to. the of y knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT P AN ON REVERSE SIDE) <br /> FOR ARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED -BY <br /> ' %ADDITIONAL COFiMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYa# DATE r; -2�1��,/ INSPECTION BY <br /> CALL FOR A-GROUT INSPECTION ]PRIOR TO GROUTING AND FINAL INSPECTION. <br /> TT 5/731M .? <br />