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V <br /> It/Ir- <br /> "�""�' SAN .TOAQtTiN LOCAL HEALTH DISTRICT <br /> TO}". OF ICE USE: 1601 E. Hazelton Ave. , Stockton►, Calif. <br /> Telephone: (209) 466-b781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE JSSUED *j <br /> . 0 Date Complete In Triplicate,) Date Issued <br /> Application is he made to the San Joaquin Local Health District � .rte <br /> and/or install the work herein described. • Th�.s application fora permit construct <br /> is made in compliance with San .Toa9u <br /> f <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District <br /> .TOB ADDRESS/LOCATION � ct <br /> CENSUS T <br /> RACT <br /> Owner's Name [�•'" � r o* � <br /> Phone <br /> Address <br /> - . . •� <br /> Contractor's Na City <br /> LicensePhone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN <br /> /_% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR - PUMP REPLACEMENT /_7 O <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA11 <br /> { SEWAGE DISPOSAL FIELDER LINES PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ----- �� <br /> TYPE OF WELL <br /> InduCONSTRUCTION SPECIFICATIONS i <br /> strial Cable Tool <br /> Domestic/private Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven ' <br /> Irrigation -- Gauge of Casing <br /> Other –=--- Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: _ <br /> Contractor 4.V <br /> Type`of Pump Iy� <br /> PUMP REPLACEMENT:e W " " <br /> / / State Done � f <br /> PUMP UPAIR: State Work Done [ <br /> �ba uJ/s' cc alb ,s <br />,DFgTRUCTION OF WELL: Well Diameter <br /> Describe Material and .Procedure Approximate Depth <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 s true. to the best m d <br /> y ow�dged belief. <br /> SIGN <br /> ITLE r6f' <br /> LO PLAN ON ER5E SIDE) --- <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS. DATE <br /> PHASE iI NS CT'ION <br /> INSPECTION BY DATEPHA II/FINAL INSPECTION <br /> INSPECTION SY DATE <br /> CALL-FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br />