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SAN JOA ' <br /> Q�CAL HEALTH DISTRICT � Ott <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Cali.f. <br /> Telephone: (209) 466-6781 -73- 3(q tom] <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit' No. <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date. Issued 6 r� 3 <br /> (Complete In Triplicate) <br /> .Application is'-hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaqui <br /> County Ordinance No. 1862 and- the;Rules and Regulations of the San Joaquin Local 'Heaith District. <br /> JOB ADDRESS/LR3L"ATI�N r 1r.01 <br /> ' i CENSUS'TRACT <br /> Owner's Name Q . <br /> - Phone`• <br /> Address City <br /> Contractor's Name �' # License <br /> �hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_� RECONDITION /_7 DESTRUCTION <br /> /77 <br /> t PUMP INSTALLATION X1 PUMP REPAIR / / PUMP REPLACEMENT ` -7 <br /> Other <br /> DISTANCE TO _NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> C-E� /SEEPAGE .PIT ZAe" OTHER /�/�� � <br /> ' INTENDED USETYPE OF WELL.f :I- N CONSTRUCTION SPECIFICATIONS �^ <br /> Industrial Cable-,.Too1.N Dia. of Well Excavation "l <br /> ,:Domestic/private Drilled_ � - _ -- _.� ..w.� _ Dia_.- of-Well Casing. . <br /> . <br /> .. 1i�e C/pylic.. .� Driven - -- <br /> Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I Other ' Rotary 3+ Type of Grout <br /> 4 Other- Other Information <br /> c - <br /> OF 19 <br /> PUMP INSTALLATION: Contractor <br /> �. <br /> t _ Type sof Pump ` �` H.P. <br /> f <br /> PUMP REPLACEMENT: / / {State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> J1ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 3 Describe Material and Procedure <br /> I hereby agree to comply with all law regulations 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 weil, 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 , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN VEC Tft ON 7 PHASE III/FINAL_INSPEC .ION ' <br /> INSPECTION BY 7 G�-y INSPECTION BY <br /> � DATE <br /> - .,* <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426,A = 7/72 M <br />