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c S JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601'-. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -, t " �� <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ad/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> B ADDRESS/LOCATION I� to /� 4f <br /> CENSUS TRACT <br /> --ier s Name p ` COY' nc <br /> 1 � ` U b�o-�/K���' � Phone �.Z� <br /> Tdress //J City <br /> Rh <br /> itractor's Name tQ .( v; License #/z� phone <br /> 'E OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION` / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other /% — <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> ErL E'sc�a�'�• �Lc�Q� C <br /> INTENDED USE V TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> L Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> MP INSTALLATION: Contractor " �,� <br /> Type of Pump — H.P. O <br /> MP REPLACEMENT: / / State Work Done <br /> 1 <Q, ups/o <br /> P REPAIR: State Work Done 11 v <br /> TRUCTION OF WELL: Well Diameter or 0 <br /> Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> -eer completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 3rmation i true to the best of my knowledge and belief. <br /> IED 7( <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> +SE I <br /> 'T.ICATION ACCEPTED BY DATE <br /> CTIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> ;PECTION BY DATE' INSPECTION BY DATE <br /> i <br /> 'ALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �w <br /> M H 1426 ,,� <br />