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-: SAN 30AQUIN LOCAL HEALTH DISTRICT 1 <br /> 1601 E. Hazelton Ave. , Stockton, -Cala£. a..:. <br /> OT'`dFFICL . SE. Telephone: (209) 466-6781 <br /> CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �� _, <br /> APPLICATION-FOR WELL G <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -- <br /> (Complete In Triplicate) <br /> Application is hereby made to .the Srn Joaquin This application iscal Health tmade inrict rcompliance a permit twith SansJoaquint <br /> and/or install the work. herein <br /> described. - <br /> t Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> County �.. <br /> f� Aa r-..�y CENSUS TRACT ' <br /> -JOB ADDRESS/LOCATION <br /> � O G6C Phone i <br /> Owner's Name <br /> City . <br /> Address\] 344,?A <br /> '+ License # � � Phone <br /> Contractor`s Name <br /> TYPE OF WRK (Check) : NEW WELL /_7 DEEPEN/7 RECONDITION_/ / DESTRUCTION <br /> Pi3MP INSTALLATION PLMp REPAIR / / PUMP REPLACEMENT <br /> Other lPIT PRIVY <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TASK WER LINECESSPOOL/SEEPAGE PIT OTHER ` <br /> SEWAGE DISPOSAL FIELD <br /> N SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTIO <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled ia-.o-f Well Casing <br /> Domestic/private a <br /> � --�--�- Driven � Gatage�of Casing <br /> Domestic/public a <br /> Gravel Pack -� Dep f Grout Seal c, <br /> OtheIrrigat--ion ;�. ,�� Rotary Type of Grout <br /> Other Information <br /> `�4r *tote <br /> i PUMP INSTALLATION: Contractor H.P. <br /> u: cr <br /> Type of Pump �T , <br /> PUMI' REPLACEMENT: / / State Work Dane <br /> PUMP 'tEPAIR: f / State Work Done 4, <br /> Approxim to Depth d <br /> 1 " <br /> ;DFsTRUCTION OF WELL: Well Diameter w C <br /> �De.scribe,Material an.d_Pro.ceduK:P_ <br /> ,r I hereby agree to comply with all laws and regulations of the San ,7oa tf Local Health District <br /> 3 and the State o€ Ccomfarnia pertaining. to or regulating well'�i'construction.� t thin FT EEN DAYS <br /> after completion of my work on a new wel13 <br /> 'T will fu , ish J� eN an Joaquin Local Health District F <br /> 5 WELL DRILLERS REPORT of tie well and notify them before putting the well in use. The above <br /> information is true to th� best of my knowledge and belief. <br /> TITLE <br /> SIGNED a a (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> i PHASE I DATE <br /> ICATION ACCEPTED -BY <br /> ADPL , <br /> ADDITIONAL COMMENTS: PSS II/F NAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE > <br /> INSPECTION BY DATE <br /> . <br /> - CALL FOR--A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. 5/731H <br /> _ __ . 1 <br />