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ra <br /> `. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF. OFFICE 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 1 YEAR FROM DATE ISSUED Date Issued 33 2y-7� <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G ,. -- i NSUS TRACT <br /> Owner's Name am, Phone <br /> Address City <br /> 24 <br /> Contractor's Name 'cense Phone 4 ,3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PLUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 13_,j- SEWER LINES PIT PRIVY <br /> '**A- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ZQ <br /> r/ Domestic/private Drilled Dia. of Well Casing A' <br /> Domestic/public Driven Gauge of Casing 42 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other T eT Rotary Type of Grout 610-41 �4m <br /> Other Other Information + <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DFCTRUCTION 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 <br /> {DRAW LO PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COINMENTS: - <br /> PHASE GROUT iSPECTI N PHASE III/F AL INSPECTION <br /> INSPECTION BY ATE - 3- INSPECTION BY (� DATE 2--2.,r-7r <br /> CALL FOR A GROUT INSPEC ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />