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y <br /> SAKI JOAQUIN LOCAL HEALTH DISTRICT <br /> i`OI. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 S= <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued J61- <br /> (Complete <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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> p <br /> j JOB ADDRESS/LOCATION 7 . ( CENSUS TRACT ' G' <br /> y Owner's Name U /`?� /�N _. ,_.... .,,.. ..,_,. ...,_ Phone <br /> Address 47 City <br /> Contractor's Name WOODS License # je' $ Phoned �� 1 <br /> T <br /> TYPE OF WORK (Check): NEW WELL IA- DEEPEN' / / RECONDITION DESTRUCTION DESTRUCTION <br /> ALf�. . yam' <br /> PUMP INSTLATION / PUMP REPAIR /—/—PUMP PUMP REPLACEMENT <br /> Other <br /> / 7 ^ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SSPQOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation fiz <br /> Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type -of Grout ee,771"i4/�" <br /> Other Other Information <br /> ODS <br /> PUMP INSTALLATION: ContractorMIELL DRO <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f / State Work Done <br /> .P_UMP,_REPAIR <br /> i .DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F i <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 /> i 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 /> i <br /> SIGNEDsl TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE I <br /> APPLICATION ACCEPTED"BY C DATE — <br />► ADDITIONAL COMMENTS: � _ -4&VV t <br /> PIIAS,,E II _GROUT INS ECT ON PHAOSE I11/FINAL INSPECTION <br /> INSPECTION BY DATE BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ,E H 1426 <br /> 54731M , <br />