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{ 0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LTO—F.. O 'FICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781.APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _/ l& F <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Rate 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 Joaquin <br /> County Ordinance .No. 1.862 and the Rules and Regulations of the an Joaquin Local: Health District. I, <br /> CENSUS TACT <br /> ,TOB ADDRESS/LOCATION <br /> k f <br /> O <br /> Phone <br /> Owner's Name 6 <br /> Address <br /> 1�d City ' ' <br /> License # Phone <br /> Contractor's Name <br /> E, <br /> TYPE OF WORK (Check) : NEW WELL I vl DEEPEN / I REC{3NI3ITION_/ / DESTRUCTION <br /> PUMP INSTALLATION f PUMp REPAIR / / UMP P EMEN / <br /> Other/ I <br /> DISTANCE TO NEAREST: SEPTIC TA;yK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �'C1 <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION. Contractor H.P. ' <br /> Type of Pump <br /> PUMP REPLACEMENT: f _J State Work Done <br /> r <br /> PUMP UPAIR: / / State Work Done <br /> ��. _ <br /> PF--T-RUCTION OF WELL: Well Diameter <br /> Approximate Depth�" <br /> a Describe Material and Procedure <br /> ;i I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> ;j <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of myworkon a new well, I will furnish the San Joaquin Local Health District t <br /> WELL DRILLERS REPORT 'of the well and notify them before putting the well in use. The above <br /> ;a information is true to the L:4 <br /> knowledge and belief. <br /> TITLE d <br /> SIGNED <br /> RAW PLOT PLAN ON REVERSE SID } <br /> i; -7FO P T USE ONLY <br /> PHASE I <br /> r APPLICATION ACCEPT DATE <br /> ADDITIONAL COMMENTS: p I / NAL INSPE N, <br /> i P I OUT INSPECT N DATE <br /> INSPECTION BY DATE > INSPECTIO Y <br /> CALL FOR A-GROUT:!-INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731-M <br /> V u 9679 _ <br />