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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR`OFFT.CE USE: 1601 E. Hazelton Ave. , Stocktoxi, Calif. <br /> Telephone: (209) 466-6781 7a'G�� <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 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 Joaquin <br /> County Ordinance No.. l nd Ae Rules and Regulations of the San Joaquin Local Health District. <br /> ' r lltt�7 <br /> k JOB ADDRESS/LOCATIONW + CENSUS TRACT <br /> i <br /> Owner's. Name Phone Srsr'3ez-101 <br /> Address "` f City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/- DEEPEN '/ / RECONDITION / DESTRUCTION /7 <br /> . .._PUMP INSTALLATION PUMP REPAIR I / t:PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEARESZ: SEPTIC.TANK SEWER LINES PIT PRIVY, <br /> SEWAGE-DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL { CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable'„Tool Dia'. of Well'-Excavation <br /> Domestic/private ! ., Drilled Dia. of We`-ll Casing <br /> Domestic/public v Driven Gauge of Casing 6 <br /> Irrigation f ;Gravel Pack \k Depth of Grout Seal r <br /> Other �� i6-Cary 4 Type of Grout <br /> h <br /> Other -Other Information' , _ <br /> PUMP INSTALLATION: Contractor di Pii/1 �. <br /> Type of Pump na. H.P <br /> __. — <br /> ✓k <br /> PUMP REPLACEMENT.: Y _/ / State Wark-Done <br /> :PUMP REPAIR: /:. / State Work-Done <br />(. .DESTRUCTION OF'WELL.: Well Diameters Approximate Depth <br /> Describe Material and Procedure <br /> E ' I hereby agree to comply with all laws .and regulations of the San Joaquin Local Health District <br /> F 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 e o the best of my knowledge and belief`. <br /> SIGNED TITLE d5z11_7_7A__.,. <br /> . (DRAW PLOT PLAN,ON REVERSE SIDE)' <br /> ' - - FOR DEPARTMENT-USE ONLY _ --- - - <br /> -PHASE T - a- <br /> APPLICATION ACCEPTED BY <br /> .DATE <br /> .ADDITIONAL COMMENTS: f <br /> PHASE •II GRO NSPECTION PHASE i I/FINA?,'- INSPECTION _ <br /> INSPECTION BY '4, INSPECTION BY”- DATE fQ ,; � <br /> 7 ,t it <br /> CALL FOR A }GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS'EC <br /> E H 1426 q v 4/7.2 1M <br /> { :C6C <br />