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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP,-4 <br /> OFFxCE 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 ,E7CPIRES ;1 YEAR FROM DATE ISSUtW k Date Issued ;. <br /> -.(Comp•le.te `In Triplicate) <br /> Application is here y trade-to Ithe'San! Joaquin Local 'HealthDistrict for a permit to,,construct <br /> and/or install the work herein described. This appl cation' i:s mad' h compliance,-,with San..Joaquin <br /> County Ordinance-No:+ 1862 and� the Rules and. Regulations of the San Joaquin.Local Health.District. <br /> JOB ADDRESS/LOCATION $ o��cNSUSRAc.T <br /> apsy� <br /> Owner' Name �� _: Phone <br /> I's � 71J <br /> Address17,7Cit <br /> g:frG <br /> Contractor's Name S-9License �',�i/ Phone S►35r 2� <br /> TYPE OF WORK (Check): NEW WELL I3EEPEN /_% RECONDITION /_� DESTRUCTION./_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other. <br /> . i <br /> DISTANCE TO NEAREST: SEPTIC TANKD! SEWER LINES PIT PRIVY <br /> SEWAGE.DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y <br /> INTENDED USE TYPE OF -WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. -of Well„ Excavation' <br /> _ Domestic/private Drilled pia. of Well Casing la <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel 'Pack Depth of Grout Seal r6�� <br /> Otliex`,,.,,- Rotary . Type of Grout - <br /> t Other Other Information - - - —� ► <br /> PUMP INSTALLATION: Contractor w <br /> Type ofd Pump _ �y13 - H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: / / State Work Done <br /> _?ESTRUCTION OF WELL: Well Diameter.:. <br /> k <br /> Describe Material a�ocedure , Approximate Depth <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 'andinotify them before putting the well in use. The above <br /> information .is true to the best of `myknowledge and belief. 99 <br /> SIGNED - 29� y 1 <br /> TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE -” <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: 3 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 3 INSPECTION BY DATE "O p <br /> CALL FOR A GROUT ,INSPECTION-PRIOR .TO.GROUTING AND FINAL INSPECTIO - - -w- - <br /> E H 1426 7/72 1M ; <br /> • . r <br />