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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF.'OFA;ICS; USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> PFrITelephone: (.209) x+66-6781 <br /> — - 11APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per No. 7Gf- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'IS$UED. Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workr herein described. ' <br /> Re$ulatiotiatofnthe Saz is eJoaquinin pLoc��e�lealt.h with &Di.strictJoaquin <br /> County Ordinance No. 18'62 and the g <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION, <br /> Phone <br /> Owner's Name <br /> Address y <br /> License 1(1 hone <br /> Contractor's Name - -°�'�' <br /> TYPE OF WORK (Check): NEW WELL Y DEEPEN '/—/ RECONDITION_/ { DESTRUCTION 1-7 <br />+ iPUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> 'Other / .{ <br /> x <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .11 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .�j Cable Tool Dia. of Well Excavation G <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing e at <br /> -- <br /> Irrigation Gravel Pack Depth of Grout $ <br /> Other Rotary Type of Grout ` <br /> f Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> H.P. ' <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DF1TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f I 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. Within FIFTEEN DAYS <br /> after completion of 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 /> I° TITLE <br /> SIGNED41 4112 <br /> �N (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED :BY <br /> ADDITIONAL COMMENTS:? <br /> PHASE I GROUT INSPECTI N P S I (FINAL INSPECTI N <br /> INSPECTION BY DATE 6 INSPECTION Bwp ( DATE 1 <br /> • CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INSN. <br /> �� 5/731rs <br />