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�s <br />_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LFOLO�TICE USIa: 1601 E. Hazelton Ave, , Stockton, Cali€. <br /> 'Telephone: (209) 466--6781 �f4�f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATH ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made to the San Joaquin Thisvcal Health a permit <br /> application-`ist�nade inrcompliance twith nSan uJoaquin ] <br /> and/or install the work herein described. - <br /> ationa o€ the San Joaquin Local health District. <br /> County Ordinance No. 1862 and the Rules and Re.gul <br /> CENSUS TRACT 2 <br /> JOB ADDRESS/LOCATION <br /> Owner's Name <br /> C _ Phone 4(& 5� 7/ 2 <br /> Address loe <br /> 4.r/ - City . TFCC/ C��-r s <br /> Contractors Name <br /> O License #9(a 6/ Phone <br /> (Check) : NEW WELL f / DEEPEN / / RECONDITION I_l DESTRUCTION Ipp / <br /> TYPE OF WORK (ch3 <br /> PUMP INSTALLATION �/ PL`MP REPAIR �/ PUMP REPLACEMENT � <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> fCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia.'of Well Casing <br /> Domestic/private - -- <br /> Domestic/public Driven Gauge of Casing <br /> �J( Irrigations Gravel Pack Depth of Grout Seal <br /> p- <br /> Rotary Type of Grout <br /> Other ; A <br /> Other Other Information ' <br />� a <br /> a <br /> PUMP INSTALLATION: Contractor H.P. d �. <br /> Type of Pump , <br /> PUPIP REPLACEMENT: / / State Work Done <br /> PUMP -tEPAIR: State Work Done = <br /> C <br /> :D -gTRUCTION OF WELL: Well Diameter <br /> ° Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> � 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 /> 3 WELL DRILLERS REPORT of the well and notify thembefore putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> TITLE 114C- <br /> SIGNED (D P PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 7 <br /> PHASE I , DATE <br /> APPLICATION ACCEPTED BY` <br /> ADDITIONAL COMMENTS: PRASE I/FINAL INSPECTION <br /> PHASE II G OUT NSPECTION INSPECTION BY DATE '7 <br /> INSPECTION BY - <br /> CALL FOR A GROUT INSPECTION PRIOR..TO GROUTING AND FINAL INS ION. 5/731M <br />