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SAN JOAQUIN LOCAL HEALTH DISTRICT � �1 7— <br /> FOR OFFICE USE' 601 E. Hazelton Ave. , �Stockton, Calif. /� 1 <br /> Telephone:' (209),466-6781 C <br /> LICATION FOR WELL CONSTRUCTIONi�OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES, 1 YEAR'FROM .,DA7?j2 •ISSUED=>' - Date Issued? 7 <br /> (Complete Itv T 1plita'te)' <br /> Applicata;oiALisnhikreby.-fmade-ito theGSan._Joaquini-Lodal; Hda-lbh District ilfor a-pei&t• t6-construe <br /> and/or install the work herein described. Thf6i:applicatloxa••ris':made 4i:n.:.compl'iance with San Joaquin <br /> County;Qrdi:naizcec:No-,-,71862a�a.ridvthd,Rube.§'and .Regulations .af6thre,San iJoaquin-Local..Health District. <br /> ca_tr}t.�.`Gyf' 'Y'ir:;�(i r .0 , 5 ,y;i`1�+Ri= .. ?r: ." --s .'?r.�: .. ,.•} aiti _� .. - 1. •ic.ir; 4 . 'r.; . <br /> JOB ADDRESS/LOCATION Q i✓ `�.CFNS`US` .TRACT <br /> Owner!s=Y-Nam@J 1.J+ e 11F "vi J:i ? ( i 7 i.)7 ?? Plio11� 7% <br /> AddressC City_ (' <br /> Contractor's Name Ifj �,.r,a„pa J� �� License # Phone <br /> TYPE OF WORK (Check) : NEW WELL, / / DEEPEN '/- / RECONDITI9N _/ DESTRUCTION <br /> - PUMP INSTALLATION / / PUMP REPAIR ZZ/ PUMP REPLACEMENT <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 .SPECIF'ICATIONS 1 <br /> Industrial . Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing f� <br /> Domestic/public Driven Gauge of Casing - M1 <br /> Irrigation. <br /> Gravel Pack . Depth. of Grout Seal. <br /> Other rotary Type of Grout __-- <br /> Other Other Information ' <br /> P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State 114ork Done <br /> _DESTRUCTION 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 Distridt 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 ITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JU(FINAL INSPECTION <br /> INSPECTION' BY DATE INSPECTION BY DATE - Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172 lM <br />