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FOE;.OFFICE USE; 1SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 601 E. Hazelton Ave. <br /> Telephone: , Stockton, Calif. <br /> APPLICATION FOR WELL CONSTRUCTION 6ORIPUMP PERMIT Permit No.,.3r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> In Triplicate) <br /> APplication is hereby made to the Sant oaq iComplete n Local Health District Date Issued <br /> and/or instal], the work herein described. - <br /> County Ordinance No. 1$62 and the Rules and Re Sulatifor a permit to construct <br /> This application is made in compliance with San Joaqui3 <br /> ons <br /> JOB ADDRESS/LO of the San Joaquin Local Health Dis�rict. <br /> > Owner's Name CENSUS TRACT <br /> Address Phone <br /> I Contractor'sName ��� City <br /> 7 License # <br /> _mow Phone , <br /> TYPE OF. WORK (Cheek ,j <br /> ., NEW WELT; {`/� DEEPEN.. <br /> ' /�-// RECONDITION /% DESTRUCTION <br /> PUMP INSTALI,ATION�/ / PUMP..,REPAIR ' /� <br /> Other .. _. PUMP REPLACEMENT /- <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK " <br /> EWER LINE <br /> SES PIT PRIVY <br /> 4 SEWAGE LD DISPOSAL FIE <br /> L _� CESSP ./SEEPAGE PIT- .� <br /> INTENDED USE OTHER <br /> TYPE OF WELL \ <br /> Indus trial <br /> �_ Cable I,001 �CONSTRUGTIOIV SPECIFICATTONS L`r <br /> Domestic/private - Dia.. of WeI,�`Excavation � <br /> Domestic _�.� Drilled ,Dia. of Well Casings �� _ <br /> /public Driven -- <br /> Irrigation Gauge of Casing <br /> .�.� Other _ Gravel Pack Depth of Grout Seal, <br /> Rotary _�y _ <br /> Other Type 'rout Q <br /> - .� Other Information <br /> PUMP INS TALLATION: <br /> Contractor ���' <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> Lk State Work Done r <br /> PUMP 'tEPAIR. "- <br /> ----- State Work'Ione `� <br /> "� <br /> .)FgTRUCTION OF WELL: <br /> ----� Well :Diameter .�i <br /> Describe Material and Procedure App <br /> y agree troximate Depth <br /> I hereby -------_ � <br /> o comg�iy with all laws and regulations; of the San Joaquin Local Health District <br /> aria the St alifornia Pertaining.�to or regulating well 'construction. Within FIFTEEN <br /> after co etion..o- ict <br /> my wo on AYS <br /> a w ell, Twill furnish the San Joaquin Local Health District a � <br /> WELL DRI et <br /> REPOR `of .the 'ell nd n tify them before putting the well in use. ab <br /> information is tru to the e . <br /> my owledge and belief. ave <br /> SIGNED <br /> TITLE <br /> W PLAN REVERSE SIDE} : <br /> PHASE I � OR�DEPARTMENT U <br /> APSE ONLY i <br /> PLICATION ACCEPTED -BY <br /> ADDITIONAL COMMN DATE <br /> P 'IG. OU IN PE N k <br /> INSPECTION BY DA _ P SE FIN SPECT 0 <br /> r� INSPECTION B AT <br /> CALL I TING AND FINAL INSPECTION <br /> E H 142626 ECTION PRIOR TO- GR . f� , <br />