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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For-OFFICE; SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephbne.: (209),, 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7GL S'6.3 fa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is iiereby 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 Dia�rict. <br /> CENSUS TRACT <br /> .TOB ADDRESS/LOCATION, <br /> Phone ' <br /> Owner's Name <br /> City <br /> Address <br /> Contractor's Name <br /> License # /9� hone ' �p i <br /> TYPE OF WORK (Check)-. NEW WELT.1111, <br /> DEEPEN "/ I RECONDITION I / DESTRUCTION I� - <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT IT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANriSEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONSA <br /> Industrial Cable Tool Ilia. of Well. Excavation '0* <br />{ Domestic/private <br /> Drilled Dia. of Well Casing <br /> ublic Driven Gauge of Casing <br /> Domestic/pIrrigation Gravel Pack Depth of Grout Seal <br /> Other T -_ Rotary Type of Grout <br /> Other Other Information <br /> j PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: ! / State Work Bone ` <br /> ' PUMP 'tEPAIR: / / State Work Done <br /> pFgTRUCTION OF WELL: Well Diameter 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 regulating 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 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. A <br /> SIGNED r lY ✓ ( f ! C�• TITLE <br /> PLOT PLAN 0 EVERSE SIDE) <br /> FOR P T T USE ONLY <br /> PHASE ID <br /> ATE <br /> APPLICATION ACCEPTED .B <br /> ADDITIONAL C0fl-1ENTS: P III/ AL INSPECT N <br /> P OUT INSPECT N \\ DATE �_7 <br /> INSPECTION BY C DATE _ �� INSPECTION�BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . 5/731M - <br />