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JOAQUIN LOCAL HEALTH DISTRICT <br /> AOR OFFICE USE: 160 Hazel tor .`Ave Stockton, Ca <br /> Telepl on& ('209) `4`66-67$1 . <br /> r^: APPLICATION FOS:WELL-CONSTRUCTION OR PUMP PERMIT Permit No;�3_/tea �• <br /> THIS PERMIT'"EXPIRES T°YEAR -FROM DATE 'ISSUED` Da"te Ysstled. <br /> - (Complete 'In Tr"tplcate) <br /> Application "isl.hereb"y' tgade"t0 fife San`J-oagiiin` Focal Health District for -a permit to constiruct' <br /> and/or install the work herein described. <br /> "Thx s application is made:in compliance with' San Jo4 ! <br /> Countyi, 0rditiatie6?lqa, 186 ii d the Rules anis Regulations of the San :Joaquin Local Health Distrif,,q <br /> JOB ADDRESS/LOCATION <br /> ` LOwner's _ i <br /> one r <br /> Address <br /> city. <br /> Contractor's Name do License ilafj-?71 Phone <br />} <br /> TYPE OF WORK"(Check): NEW 'WELL / DEEPEN /_7 RECONDITION /? DESTRUCTION J <br /> PUMP INSTALLATION /,J PUMP REPAIR / / PUMP REPLACEMENT: /� <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 /> Industrial . . Cable Tool Dia, of Well Excavation Ad ri <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> �:Domesti' <br /> c ublic <br /> /p . Driven Gauge of Casing / - <br /> Irrigation Ifv;-Gravel Pack Depth of Grout Seal oLDfJ - <br /> Othee <br /> tr'Rotary Type of Grout (' <br /> Other: Other Information 4 <br /> PUMP INSTALLATION: Contractor <br /> Type- of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / ` State Work Done <br /> .kESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> # Describe Material and Procedure <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 riew 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 a <br /> information is rue to the best f my nowledge and belief. <br /> SIGNED <br /> -TITLE �- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � _ <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL COMMENTS: i <br /> .PHASE I G I S <br /> PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATErZZ/7- INSPE ION BY DATE i <br /> CALL FOR.A :GROUT. INSPE. ION .PRIOR TO.. GROUTING. AND FINAL INSPECTION. <br /> E ii`•-1426 4 " 7/72 1M j <br />