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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'Of. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. + <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. T �lJlr1 <br /> G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -.' - � <br /> (Complete In Triplicate) <br /> Application is hereby rude tolthe 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.. 186 an Ithe Rules and Regula <br /> of the San Joaquin Local Health District. <br /> � CENSUS TRACT <br /> JOB ADDRESS/LOCATIO - <br /> Phone <br /> Owner's Name f r <br /> City . . <br /> Address <br /> License 4� ��Phone <br /> Contractor's Name �. . <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ J RECONDITION_/ J DESTRUCTION /_7PUMP INSTALLATION J / PUW REPAIR / J PUMP REPLACEMENT / pa <br /> Other/ J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE :OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable- Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other t Rotary Type of Grout <br /> i <br /> Other Other Information <br /> E <br /> PUMP INSTALLATION: Contactor H.P. <br /> Type of Pump l <br /> PUMP REPLACEMENT: / / {State Work Done <br /> PUMP '2EPAIR: / / State Work Done - <br /> DF�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Desc ibe Material. and Procedure <br /> I hereby agree to comp]y 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 /> ll furnish the San Joaquin Local Health District a <br /> after completion of my work° on a new well, I wi <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 /> i SIGNED <br /> f (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> P1iASE I DATE s <br /> {G APPLICATION ACCEPTED .BY <br /> ADDITIONAL CO:gfENTS: P /FINAL INSPECTION <br /> p GR T INSPECTION DATE <br /> INSPECTION BY DATE -�� INSPECTION BY lY�• <br /> CALL FOR A T iN5PECTION PRIOR TO GROUTING AND FINAL INS ION. 5/731M <br />