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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.or..OrPICU' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ',j_.5 8- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / _1 �i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaq <br /> County Ordinance No. 1862 and the Rules and RegulatiorVi, of the San oaquin Local Health Dis�rie <br /> CENSUS TRACT OS_ 3��0�� <br /> JOB ADDRESS/LOCA ON O <br /> Phone <br /> owner's Name <br /> �G City <br /> � Address a=���•�---�-- <br /> :.. �. icense ��7hone <br /> Contractor's Name - - _ — _ <br /> TYPE OF WORK (Check) :�NEW WELL/ / DEEPENCONDITION _ DESTRUCTION <br /> ' PUMPPUMP REPAIR/ / PUREPAIR/ / PUMP REPLACEMENT /� <br /> + Other / / <br /> DISTANCE TO NEAREST: . -SEPTIC TA;iK SEWER LINES PIT PRIVY <br /> SEWAGE DISP L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> !l <br /> INTENDED USE • :TYPE OF WELL CONSTRUCTION SPECIFICA ONS <br /> F Industrial "I` able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dom tic/public Driven Gauge of Casing <br /> fl Gravel Pack Depth of Grout Seal �- <br /> rrigation r,r.---- <br /> Rotary Type of Grout <br /> Other E Other Other Information , - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P.P. <br /> r -"PUMP`REPLACEf1ENT:" `- `/�/- State-Work-Done <br /> PUMP UPAIR: / / State Work Done <br /> 11 Diameter <br /> DRqTRUCTION OF WELL: WeApproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri, <br /> and the State of California pertaining to or regulating well •construction. Within FIFTEEN DA' <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri <br /> WELL DRILLERS REPORT of the 1 and notify them before putting the well in use. The above <br /> information i true t the' e of my knowledge and belief. <br /> TITL6�e--ASIGNED <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> j PHASE DATE <br /> APPLIC ' ION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION INSPECTION <br /> III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .,.„,..•,• T**c�Lf TTl1TJ.rR7nn Tn C:ROUTING AND FINAL INSPECTION. <br />