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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> I�� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> IOC. OI ICE USE: Telephone: (209) 466--6781 <br /> 74 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNA? PERMIT Permit No. � <br /> Date Issued <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUEDZ`� <br /> (Complete In Triplicate) permit to constrict <br /> Application is hereby made to the San Joaquin Local i HealthDistrict <br /> is made inrcompliance with San Jp�o qui-n <br /> pP <br /> and/or install the work herein described. This applzca <br /> County Ordinance No. x.862 az:d ,the Rules and Regulations of Che San Joaquin Local ii.e�.3].th District. <br /> ��• CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone �S <br /> i <br /> Owner's Name <br /> City - <br /> Address <br />` Contractor's Name <br /> License # 460Phone (Z� ff 771 <br /> Check NEW'WELLDEEPEN '/ / RECONDITION /_/ DESTRUCTION !�T <br /> OF WORK (Check) : — PUMP REPLACEMENT /� <br /> E TYPE PUMP <br /> LLAT ION / / PL'NfP REPAIR / / <br /> Other <br /> /��, SEWER LINES 'PIT PRIVY b <br /> DISTANCE TO NEAREST: SEPTIC TANK --4 ---- _ <br /> SEWAGE DISPO Ai, FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL --- <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial Dia. of Well Casing <br /> ~� Domestic/private � � Drilled <br /> Driven Gauge of Casing eal <br /> s <br /> Domestic/public Gravel Pack Depth of Grout S <br /> Irrigation <br /> y Rotary . Type of Grout <br /> Other Other Other Information <br /> F'tTi+3P INSTALLATION: Contractor H.P. :' <br /> Type of Pump <br /> PUMP State Work Done <br /> UMP R <br /> [ 1 <br /> PULP 'tEPAIR: / / State Work Done <br /> �` } i <br /> j Approximate Depth <br /> DESTRUCTION OF WELL: We11-Dia�eter <br /> Describe Material and Procedure <br /> rict <br /> C F <br /> I hereby agree to comply with all San <br /> laws odorelnowell�'construction.LoWithin aFIFTEEN lth tDAYS <br /> and the State=of California pertainingregulating <br /> after completion of my work on a new well, Ithelmlbeforesputtingh the atheowell Local Health <br /> above <br /> i WELL DRILLERS REPORT o€; the well anti notify <br /> information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED ` (DRAW PLOT PLAN Oi3 REVERSE SIDE <br /> _ F DEPARTMENT USE ONLY <br /> a <br /> PHASE I '�...� :�. •,. DATE- _ <br /> APPLICATION-ACCEPTED:B _ -�-- — <br /> ADDITIONAL COMMENTS: n �� PRASE III/ INAL. INSPECTIO <br /> PIfASE II GROUT INSPECTION s INSPECTION BY y, DATE <br /> INSPECTION BY DATE a. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br />