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N <br /> SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> '0r­01TFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES l 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 Joaquin <br /> Count O;dananc cr�86,2&a d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS jLOCATION zi v 7 e c-,,4-- - AI/4 G u/{�I �C �(I` �NJUS TRACT ��-m-z.v-t( <br /> Owner's Nam [.�/Sr ti c�— ( Phone <br /> Address City <br /> Contractor's Name N S: S' License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION 17 DESTRUCTION /-7 N <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other M �L <br /> T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> 1--- ndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> .7 <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 <br /> Type of Pump tc H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> r <br /> DF-,TRUCTION OF WELL: Well 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE u�� �''✓�`� <br />' (DRAW PLOT PLAN ON REVERSE SID9) <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE R120 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE W G OUT INSPECTION P S ' I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E. H 1426,,. 5/731M <br />