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SAN JOAQUIN LOCAL HEALTH DISTRICT �{ <br /> .FOL. O17.l'I;CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nor!`i - <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued Id-3.-,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 Sari Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION / , - CENSUS TRACT " <br /> I <br /> Owner's Name _ �Q ® � ,�� Si�ica �yt Phone ��^. y ,Zr { <br /> Address _ 7A.6 rl �,�;fj'`�•ffArY Cit <br /> WOODS WELL DRILLING <br /> Contractor's Name _ ed License #ggggA�Phone <br /> 11944 74A-2407 —_745-3247 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION "/ <br /> PUMP INSTALLATION / / PUMP REPAIR/ I PUMP REPLACEMENT I� <br /> Other / V — <br /> I <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 f�- Cable Tool Dia. of Well Excavation qr <br /> Domestic/private Drilled Dia. of Well Casing <br /> 'Domestic/public Driven-. Gauge of CasingJA <br />` Irrigation j - �` Gravel Pack Depth of Grout Seal .549 <br /> Other `'- Rotary Type of Grout &,z d <br /> Other Other Information �r <br /> PUMP INSTALLATION:'% Contractor <br /> Type of Pump t II H.P. <br /> PUMP REPLACEMENT: / / State Work,Done <br />^PUMP""tEPAIR: a. _ —/-/--'State'I ork-Done��f <br /> ,DFgTRUCTTON'°OF WELL: Well Diameter Approximate Depth r <br /> Describe Material :and Procedure <br /> I hereby agree to .comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the State of Califoruia. 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 /> [,SELL DRILLERS REPORT of .the well.. and notify them before putting the well in use. The above <br /> r information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � l <br /> APPLICATION ACCEPTED BY 41° DATE / � 7Y <br /> ADDITIONAL COMMENTS: <br /> PHASE i GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /0 INSPECTION BY -DATE <br /> SCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 '~,` :. 5/731M -- <br />