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cxg JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: / 1601 . Hazelton Ave. , Stockton, Calm <br /> YJ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77L_5_� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> -.id/or install the work herein described. This application is made in compliance with San Joaquin <br /> 3ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _)B ADDRESS/LOCATION <br /> CENSUS TRACT <br /> '*-mer's Name L1 Phone <br /> rddress City <br /> intractor's Name <br /> 33" <br /> License �E� „L�� Phone <br /> PE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <br /> • Other / / <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (J <br /> Industrial Cable Tool Dia. of Well Excavation tit <br /> 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 /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: State Work Done <br /> -1P REPAIR: / / State Work Done <br /> v� <br /> PSTRUCTION OF WELL: Well Diameter Approximate Depth \`^ <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> mer completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> z'LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> "ormation is true to the hest of my knowledge and belief. <br /> [GNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> SSE I FOR DEPARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY - DATE S <br /> ►ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 4SPECTION BY DATE INSPECTION BY . , DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> +E H 1426 * 7i-Y,) ,M <br />