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. SANQUIN LOCAL HEALTH DISTRICT <br /> "OFFICE USE. 1601 E. ..azelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ��(( <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Id <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued — <br /> (Complete In Triplicate) Issued . <br /> Scation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> or install the work herein described. This application is made in compliance with San Joaquin. <br /> y Ordinance No. 1862 and the Rules an egu4tion of the San Joaquin Local Health District. <br /> 1. DDRESS/LOCATION r. -cicGt, CENSUS TRACT <br /> 's Name _ F r iv Phone <br /> 'ess � 'D�lf-, /� �� �/ ., ,.�. /' City /p ./..� <br /> actor's Name. F License 0� Phone <br /> FOF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /—T <br /> PUMP INSTALLATION / / PUMP REPAIR / ,/ PUMP REPLACEMENT /_7 <br /> Other <br /> -NCE 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 /> Industrial i. Cable Tool Dia. of Well Excavation <br /> F. Domestic/private Drilled Dia, of Well Casing <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 /> INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> REPLACEMENT: / / State Work Done <br /> FREPAIR. / / State Work Done <br /> F—UCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> by agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> he State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> REPORT of the well and notify them before putting the well in use. The above <br /> r�RILLERS <br /> ation is true to the best of my knowledge and belief. <br /> ED TITLE <br /> (DRAW PLOT PLAN ON REVERSE' SIDE <br /> FOR DEPARTMENT USE ONLY <br /> E I <br /> ATION ACCEPTED BY ,� DATE 7i�17 <br /> ZONAL COMMENTS: <br /> PHASE IIS ROUT` INSPECTION - PHASE III/FINAL INSPECTION <br /> rL <br /> TION BY DATE I"' INSPECTION, _BY DATEL FORA GROUT INSPECTION PRIOR TO GROUTING'--AND FINAL INSPECTION. <br /> H 1426 7I7? Tm !'ice <br />