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�0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. t71k1ICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 } ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUAPERMIT Permit No. Ty� /y 7./dMP <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued 3 <br /> (Complete In Triplicate) <br /> Application is hereby Made to the San Joaquin Local <br /> application <br /> pplicati n isDistrict <br /> made infor <br /> com ]-lancetwithconstruct <br /> Joaqui <br /> and/or install the work herein described. ' This app <br /> P <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin--Local 1lealth District. <br /> T CENSUS TRACT <br /> JOB ADDRESS/LOCATION G <br /> �) Phon�`J 0 � V <br /> Owner's Name !c/.. � 1 <br /> Address <br /> Contractor's Licensehonel��� �" <br /> C tor's Name - _ - -- ; <br /> za1. -h � T-+i!<.:e:♦ �ss� -ter_ �_-_ - — — _ — _ _ � _ - <br /> TION 1-7 <br /> TYPE OF WORK (Check) : NEW.WELL / I DEEPEN �1 RECONDITION /—/�EREPLACEMENT 17 <br /> PUMP INSTALLATION / / Fv'MP REPAIR { I <br /> other <br /> DISTANCE TO NEAREST. SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria <br /> 1 Cable Tool Diarbf Well Excavation `► <br /> Drilled: .�. cilia. of Well Casing- <br /> Domestic/private . <br /> I Domestic/public <br /> Driven Gauge of Casing <br /> - Irrigation Gravel- `Pack Depth of Grout Seal <br /> Other Rotary � `�`: Type of Grout <br /> Other ' Other Information <br /> PUMP INSTALLATION: Contractor <br /> 1 <br /> Type of Pump • <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> } <br /> Approximate Depth <br /> DF-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 4 + <br /> I hereby agree to comply with all laws and regulations of the San Joaquin I.oWithin aFIFTEEN tDAYS <br /> and the State of California pertaining to or regulating well construction. <br /> after completion o£ my wont on a new well, I wi11 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 ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> � OR TMENT USE ONLY . � / <br /> aPHASE I � � DATE <br /> APPLICATION ACCEPTED -BY <br /> ' ADDITIONAL COMMENTS: <br /> �IASE II GROUT INSPECTION PHAS• III/FINAL INSPECTION <br /> P <br /> DATE INSPECTION BY <br /> INSPECTION BY DATE �� 7`� .. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP CTION. 5/7 3 1M <br />