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SAN JOAQUIN ;0_rAL.,IEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 Y <br /> APPLICATI.ON FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. <br /> :THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> ! (Complete In- Triplicate) <br /> Application is;hereby made�,to the San Joaquin Local Health 'District for a .permit to construct <br /> and/or install the work herein described. This i%gftone <br /> compliance with San- Joaquin <br /> QPpaty_Ordinance No 1862 and-the Rules and Reguin Local Health District. <br /> l3zaRES-S/LOCATXON <br /> 7 CENSUS TRACT' <br /> Owner'saNa <br /> r:x <br /> Address <br /> 3 city. <br /> Contractor's Name !�,[J / cense #c <br /> hone <br /> jj <br /> I <br /> TYPE -OF. WORK Check):ANEW:WELL; pEEPEN /_ REc�NDITION /_i�.s STRUCTION-/ f <br /> PUMP-INS AL TION—-•-_- <br /> / / PUMP-REPAIR//"""PUMP"REPLACEMENT /?j <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN IT PRIVY <br /> � r <br /> SEWAGE DISPOS FIELD CESS OOL/SEEPAGE PIT OTHER +.b <br /> 1 <br /> INTENDED USE <br /> TY �OFWELL� CONSTRUCTION SPECIF IONSIndustrial ; a Tool Dia. of Well Excavation <br /> Domestic/private Domestic/public Drilled Dia. of Well Casing �� + <br /> Driven Gauge of Ca'sing ; <br /> Irrigation Gravel Pack ,..", `` Depth -of Grout, Seal i� <br /> AOther Rotar <br /> �-- y Type of Grout <br /> InfozMat ori' "" <br /> PUMP INSTALLATION: <br /> l <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: J / State Work Done } <br /> F <br /> PUMP REPAIR: i f <br /> State Work Done r <br />;DE'STRUCTION 0 WRI, .: Well ameter <br /> .r Approximate Depth <br /> Describe Material and Procedure ✓, —�-- <br /> A, <br /> I hereby agree to comply withiall laws and regulations of the Sari/Joaq:uin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work ori a new well, I will furnish the San Joaquin Local health District a <br /> WELL DRILLERS REPORT of the wel and notify them before putting the we11 in use. The above <br /> information i rue to the t s of my �howledge and belief. <br /> SIGNED <br /> TITLE <br /> ( LOT PLAN ON REVERSEPHASE SIDE <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .> tr "' � <br /> ADDITIONAL`CO�}MENTS DATE <br /> ; J <br /> t <br /> PHASE II GROUT INSPECTION PHASE I INAL ;INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL-INSPECTION. <br /> E H 1426 T 4172 1M <br />