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SAN JOAQtJINw1OCAI. HEALTH DISTRICT <br /> Ol1ICL USE"• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ---- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> Date Issued ? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `— �' <br /> (Complete In Triplicate) emit to construct <br /> Application is hereby made to the San Joaquin LacalHealth gistmade inrict rcamp�.iance with San Joaquin <br /> and/or install. the work herein described. ' This application <br /> County Ordinance No. '1862 and the Rules and Regulations of the San Joaquin Local ktealth District. <br /> � CENSUS TRACT _ <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name �7 <br /> City C� <br /> Address cG - <br /> License 4akf�Phon G� <br /> Contractor's Name <br /> TYPE OF WORK (Check)-.. NEW WELL - DEEPEN <br /> PUMP INSTALLATION />j P I /L��R�EPAIR�/N// pUMPESTRUCTION REPLACEMENT77 <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TALK -06 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/d d CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE � <br /> OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 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 S <br /> Pd <br /> 3 r 7 <br /> PUMP INS IALLATIO'N a Contra'p/c <br /> HP. <br /> Type of Pump • ' <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> i ,DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> r' <br /> ! 1 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. Wit3iinFIFTEEN DAYS <br /> :after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS RE T of the well and notify them before putting the well in use. The above <br /> informa ion i true to the best of my knowledge and belief. <br /> .- <br /> SIGNED fTITLr <br /> - r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E (.0 / <br /> APPLICATION ACCEPTE 1 <br /> ADDITIONAL COMMENTS:: , <br /> PHASE .11 GROUT I PEC P E II FINAL D PEC <br /> DATE INSPECTION BY - DATE _ <br /> INSPECTION BY - _ <br /> --CALL-FOR-A-GROUT,INSPECTION PRIOR TO GROUTING AND FINAL INSPEgTION. - .-- } <br /> 5,,/731M <br />