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SAN JOAQUIN LOCAL HEALTH DISTRICT `/G6- Ile Zf <br /> FOR OFFICE USE; 1601 E. Hazel.ton'Ave .',,'Stockton, Calif. <br /> Telephone:. (209)-,--46616781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z 5 3 L x <br /> THIS PERMIT EXPIRES -I.EYEAR FROM!DATE'•ISSUED Date Issued - 7 Z= g <br /> o`Tiplicate)'(Complete In <br /> Applicati:ont.is -hereby-:,ma.de=Ito the S.an Joaquin Local Health District -for:a%permits to construct <br /> and/or install the work herein described. This .application is-made -in -compliance with San"Joaquin <br /> County_Ox-dinancecNo.<1862. and,the .Rules and Regulations-of.'th:e.San Joaquin LacaI Health District. <br /> r_r --1- <br /> .,fid ':t ; '-`� -�i^ra ;� i, . . �-, t 1, t , •. •: ;� � <br /> JOB ADDRESS/LOCATION 'C� �� CENSUS TRACT.': �0 <br /> aL17 �,+ { .. L {. •..k ..to 1: �. ,j . i ! C� S <br /> Owner'.s.4 .Phone <br /> Address 3 45 City.. �. �► a _ <br /> Contractor's Name ��.L - - License dw-, I-rJphone-7q,Jr034- <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN'/ / RECONDITION /-7 DESTRUCTION I� � <br /> PUMP INSTALLATION/ / PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other. / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK /L SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> - s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial le Tool Dia. of Well Excavation / V <br /> , mestic/private Drilled 'T Dia.. of Well Casing D e� �b __ CI <br /> Domestic/p4blic Driven Gauge of Casing a "d <br /> . a <br /> Irrigation Gravel Pack Depth of Grout Sea �is <br /> Other Rotary Type of Grout <br /> f Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> , Type of Pump H.P. �. <br /> PUMP REPLACEMENT: / / State Work Done n, <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter L 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 a 1...�\der ] 4- 451st% ?-S -- _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE T <br /> APPLICATION ACCEPTED BY DATE " aS <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALF_. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _ ._ ,.. .._.. ... .._ ,.b . - -- <br /> E H 1426 4172 1M. <br />