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SAN J. OAQUIN bOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7.2'`�aW <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDT, Date Issued /_-,Z-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. 1862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name _ mss_ �' � _ - Phone r . <br /> sAddress c C, -- City <br /> r License #.200 hone <br /> Contractor's Name /�Il�C"r-�� � —.� . <br /> :TYP.E--QF WORK�(.Check) :�y-NEW WELL •;(�..-DEEPENT 1-7.RFf.?NDLTION�/�,-DESTRUCTION- <br /> PUMP INSTALLATION t�Z PUMP REPAIR / / PUMP REPLACEMENT IrT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing '. <br /> Domestic/public _ Driven Gauge of Casing / 70 <br /> N <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Other Rotary Type of Grout . <br /> Other Other Information ' <br /> r:. <br /> 4 PUMP INSTALLATION: Contractor* <br /> Type of Pump 11.P. <br /> PUMP• REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> - --Approximate-De �-�� --� .- <br /> ,pESTRUCTION �OF"WELL: We111Dia�eter --- '""— �.. `N" `" - """"�`- .. 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 th gpil and notify them before putting the well in use. The above <br /> } information is a best of my ow ge and belief. _ <br /> { SIGNED TIT <br /> (DRAW PLOT PLAN ON REVERSE S E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,.:. rz> M r <br /> APPLICATION ACCEPTED BY DATE b�.. <br /> F ADDITIONAL COMMENTS; K:i <br /> PHAS II ,GROUT INSPECTION P S FIN NSPECT N <br /> INSPECTION BY DATE //_/—T Z- INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT-1 <br /> E H 1426 4172 1M <br />