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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ;OFFICE USE: 160, Hazelton Ave. , Stockton, Ca . <br /> Telephone: (209) 466--6781 <br /> 'APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�,5}a <br /> ii <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> €, i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health. District for a permit to construct <br /> and/oar install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations ofthe <br /> 7 'San <br /> nnvJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i <br /> Owner i's Name <br /> Phone <br /> Address Z,2 Q6 City <br /> i p <br /> Contractor's Name License # Phon <br /> ii <br /> I i� ip <br /> I TYPE OF WORK (Check): NEW WELL DEEP /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 — <br /> liit <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ;I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> .Domestic <br /> /private '� � Drilled Dia. of Well Casing <br /> 'Domestic/public Driven Gauge of. Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> lOther ) Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ' f <br /> Contractor <br /> Type of Pu <br /> H.P. <br /> s� j iE --� <br /> PUMP REPLACEMENT: / / State rk Done <br /> j <br /> PUMP REPAIR: State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure } <br /> I hereby agree to;comply with all laws and regulations of the SanJoaquin Local Health District <br /> and ttie State of Califonia peatining to or regulating well construction. Within FIFTEEN DAYS l <br /> after-j�cdmpletion of my work on axew 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 /> information is true to the best of my knowledge and belief. <br /> it •i , <br /> SIGNED TITLE <br /> .II PLOT PLAN N VERSE SI E <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS- !I' <br /> !I PHASE II GROUT INSPECTION PHAIII AL INSPECTION <br /> INSPECTION BY �' DATE INSPECTION BX DATE <br /> �a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 'I _ 7172 IM <br /> i <br />