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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF": SEE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-•-6781 <br /> ' r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _!!_-7� i <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 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 D3.s�ri,ct. i <br /> / CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner`s Name "'' <br /> City <br /> Address <br /> r o <br /> License. ,..._-.._.. Ph ne t <br /> Contracto'r's Name <br /> _ �_ —'�,s _ t'+. _ —_ <_ •�' ___ } � - .- _- _ tial <br /> TYPE OF WORK-(Check.) : NEW WELL DEEPEN / / RECONDITION /_/ ' DESTRUCTION /_7 <br /> PUMP INSTALLATION �� PUMP REPAIR L� PUMP REPLACEMENT /� <br /> Other / / <br /> u <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY' r ,O HER <br /> ^-�- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS rr <br /> INTENDED USE TYPE OF'WELL' CONSTRUCTION SPECIFICATIONS <br /> Industria3 Cabl Tool Dia. of We11 Excavation yr <br /> lleil"_ s _—Dia..Dia.. of Well Casing-_ - <br /> f"`"" Domestic/p Driven Gauge of Casing <br /> ;Ok, Domestic/public <br /> rIrrigation <br /> Gravel Pack Depth of Grout <br /> Rotary Type of Grout D <br />' ►Other <br /> Other Other Information <br /> 4 <br /> � <br /> t <br /> P 11P ,INSTALLATION: Contractor i, H.P. ' <br /> Type of Pump <br /> F <br /> PUMP.;-REPLACEMENT- State Work Done, <br /> -Do— <br /> PUMP 'tEPAIR: - / State-W rk-Done <br /> j Approximate Depth <br /> DF�TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Y <br /> t I' iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t <br /> I and''t.he State of California pertaining to or regulating well ''construction. Within FIFTEEN DAY <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 /> inti formaLon-is- true,to-the-best-.of my.knowledge-.and,.belief. <br /> R TITLE <br /> ' SIGNEDk � <br /> I _ (DRAW .PLOT PLAN oN REyERSE-SIT?E1 _ <br /> r ` FOR DEPARTMENT USE ONLY <br /> PHASE IF <br /> . s>. ♦ DATE <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 6L- O <br /> INSPECTION BY DATE - <br /> } CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION,. ~ <br /> S/731m <br /> _. 11.'74 _ .. . <br />