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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOE OFFICE USE: 1601 E. Hazelton Ave.:, Stockton, Calif. <br /> Telephone: (.204) 466-6781 ol <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITft--emit No,. 711-3/d <br /> r� THIS PERMITEXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <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 Joaquitz <br /> County Ordinance No. -1862..-and the Rules and Regulatio'ns:of, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION., . 1a CENSUS TRACT <br /> Owner's Name Phone ..i. <br /> Address _�. _- City <br /> Contractor's Name License #2v07 5?V Phone 4/1, - 12 / �# <br /> TYPE OF WORK- (Check) : .NEW WELL X DEEPEN I! RECONDITION ISI DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing � f <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other ::X: Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type'of Pump H.P. ; <br /> - i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: f% S:tate Work Donee S <br /> — <br /> .DFGTkUCTION OF WELL: 'We11 '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 new 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 /> informatio is true to he best of my knowledge and belief. <br /> P <br /> SIGNED TITLE p �, <br /> ai <br /> (D W PLOT PLAN ON REVERSE A <br /> ZOR <br /> DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> _ i <br /> APPLICATION ACCEPTED BY � DATE - r <br /> ADDITIONAL COMMENTS: <br /> PHASE II G I S ,C Oi PHAS II FINAL INSPECTI N <br /> INSPECTION BY AT INSPECTION BY DATE s <br /> CALL F'OR--A ,GROUT INSPECTION PRI R TO GROUTING AND -FINAL INSP ON. <br /> E H 1426 5/731M <br />