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y SAN JOAQUIN LOCAL HEALTH DISTRICT 076 <br /> FOF..O1FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 166-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , -5 At;,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) Z2{o--I&o-! `-( <br /> Application; is hereby made to the San Joaquin Local Health District for a permit to constl.'uct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> r �--�•- ^�� NSUS TRACT <br /> .TOB ADDRESS/LOCATION Mr. ° - <br /> . Phone �� '7�� <br /> Owner's Name <br /> Address <br /> f <br /> city . <br /> Contractor's Name License �L Phone <br /> a <br /> NEW WELL / DEEPEN '/ / RECONDITION I I DESTRUCTION /-7 <br /> TYPE OF WORK (Check} ^� <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /� J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Is <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private. Drilled Dia. of Well Casing �r <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / /` State.Work.Done- - — -� <br /> DFgTRUCTION OF WELL Well Diameter Approximate Depth 3 <br /> Describe Material and Procedure <br /> II hereby agree to comply with all laws and- reg-ulations of the San Joaquin Local Health District R <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 <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 /> SIGNED PA TITLE _ - <br /> (DRAW PLOT PLAN ON REVERSE Si <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION � PHASE III FINAL INSPECTION e <br /> INSPECTION BY !/ DATE r� -� �s _ INSPECTION BY /' DATE <br /> CALL FOR A -GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />