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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. <br /> 160I EHazelton Ave. , Stockton, Calif. <br /> 'OT.-OkF ICL USE: 5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 6_ -.,-76 <br /> (Complete In Triplicate) ict <br /> Application is hereby rade to the <br /> aquThisLocal <br /> a}ip]icatianD .stxnade inrcompliance a permit twith-n5anuJoaquin <br /> and/ar ,install the work herein escribed <br /> County Ordinance No. .1.8c12 anh_thp- Rules and �gulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> city ' <br /> Address <br /> License # Phone <br /> Contractor's Name <br /> RECOTYPE OF WORK (Check) t NEW WELL / / DEEPEN ' / pATRZO // pUMPEREPLACEMEIVT� <br /> C /7 <br /> PUMP INSTALLATION /I'f" PUMP <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> k SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> I� Domestic/private Drilled Dia. <br /> of Well Casing <br /> -- Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I PUMA INSTALLATION: Gantrar-tor IlLa H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / ./ Stag Work Done <br /> PUMP nPAIR: / / . State Work'Done <br /> Approximate Depth <br /> EDF-r-TRUCTION OF WELL: Well Diameter <br /> �r <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Realth District <br /> and the State of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion o€ 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. <br /> ` TITLE <br /> SIGNED 7 .� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I DATE ��S�2 _ <br /> APPLICATION ACCEPTED .BY �` <br /> ADDITIONAL COMMENTS: P T / I INSPECTION <br /> r PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5 r73 1M <br />