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SAN JOA <br /> QUIN LOCAL HEALTH DISTRICT <br /> FOf: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> —_ <br /> Telephone: (209) 466--6781 7�a/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� �Pv C� uJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . 7Y <br /> (Complete In Triplicate) <br /> Application is hereby made to t1je San Joaquin al Health D strict for a permit to eons t'��ct <br /> and/oCounty install the wnrk62eanint e t33e cK�iVe,,, <br /> ithan <br /> Count Onstallce No. a <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name JimbPhone <br /> Address _ City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / RECONDITION /_�/ DESTRUCTION /7 <br /> TA - <br /> PUMP INSTALLATION /X PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE: TO DEAREST: SEPTIC TANK � �- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYP OF WELL CONSTRUCTION SPECIFI.CATj.QNS <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 <br /> - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP 'WHIR: / / State Work Done <br /> .DFcTRUCTION OF WELL: Well':Diam ter 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 /> informat� true t th best of my knowledge and belief. <br /> SIGNED - TITLE �� <br /> (DRAW PLOT PLAN ON REVERSE SIp ) <br /> PHASE I FOR DEPARTMENT DISE ONLY <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL =DENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY • ,.,,, - DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. C <br /> E H 1426 /7 <br />