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_ SAN. JOAQUIN LOCAL HEALTH DISTRICT <br /> "OF. OFFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., s uJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2 to�5--/2�.0 3 t-f <br /> Application is hereby made to the Sart 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> L-7-0 aeZ <br /> JOB ADDRESS/LOCATION FAqT FND Op MF:T,T,O RT)_ - --— - CENSUS TRACT _ <br /> Owner's Name Phone r�qK q <br /> h <br /> Address 20$06 S. CARROLTON RD. _ _•_ _ City RTP(yg <br /> Contractor's Name aNNINGS $ROS. DRIT.T.TNG r.n. .jNC. _ License # I I jr,3p Phone 5p <br /> 2500 W. _RjjM_RTR RD. , MODESTO <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN / / RECONDITION / / DESTRUCTION /_7 4 Imo' <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /_7 p <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK S6jP SEWER LINES PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> . j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7nis <br /> Domestic/private Drilled Dia. of Well Casing 122 <br /> Domestic/public Driven Gauge of Casing 1/16" <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> ' Other X Rotary Type of Grout �f <br /> Other Other Information Slab-by_ owner <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pum H.P. <br /> P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> i PgTRUCTION 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 /> t <br /> SIGNED TITLE <br /> (POW PLOT PLAN ON REVERSE SIDE) <br /> yr FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTVa BY DATE A� Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II NAL INSPECTION <br /> INSPECTION BY - DATE INSPECTI N BY DATE - <br /> CALL4fFOR••A -GROUT INSPECTION PRIOR TO GROUTING AND FINAL I SPECTION. <br /> E a 1426 5/731M �� <br />