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SAN JOAQUIN L,OGAL._HEALTH DISTRICT <br /> For. OFFICE USE: F 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 -�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) a permit <br /> Application is hereby rude tdescribed. , This application ishe San Joaquin Local Health tmade inrcompliancetwithnSanuJaaquin; <br /> and/or install the work herein <br /> n <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .275 /V, •.Si oiV �S%, <br /> CENSUS TRACT <br /> Owner's`Name <br /> cityAL <br /> L <br /> Address <br /> �aicensej 4 .Phone y. 2S� <br /> Contra-c-tors �iame, --� <br />�. __ <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN. _% RECONDITION / ./ DESTRUCTION -- <br /> PUMP INSTALLATION /fPLW REPAIR/ / PUMP REPLACEMENT �� <br /> other / 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY <br /> CA <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 00 <br /> N. <br /> ONSTRUCTION 5PECIFICATI NS <br /> 4- INTENDED USE TYPE OF WELL r. <br /> n" t Industrial Cable Tool Dia. of Well Excavation X <br /> Drilled <br /> Domestic/prDia. of Well Casing <br /> Domestic/private <br /> i Domestic/public <br /> ivat Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal .SAO <br /> Other -ZT Rotary Type of Grout T Cdg,449-4i ! y2 <br /> � -. Other Other Information <br /> l T Contractor s M� LL ')R Ll PUMP I1�STALLATION: H.p. <br /> F Type of Pump <br /> PUMP REPLACEMENT: <br /> State Work Done 21v <br /> PUMP 'ZEPAIRt;-- / / State Work Done T <br /> s ,DF--TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> i e Describe Material and Procedure <br /> - <br /> IA ` <br /> i <br /> ;j I hereby agree..-to compl}►;.with all laws .and regulations of the San Joaquin Local Health Distr strict <br /> and the State ofrCaliforiiia pertaining to or regulating �rell''construction. Within FIFTEEN RAYS <br /> after completion of ray work on=a new well, I will furnish the San Joaquin Local Health District <br /> oyp <br /> WELL DRILLERS REPORT � -,-the well and notify them before putting the well in use. The ab A <br /> •.�-� <br /> infor`ma�tion-�i � r-ue, to--the-�b�s of my knowledge and belief. <br /> t <br /> SIGNE _ _ — TITLE , 4olel 'ii�ii <br /> REVER <br /> Nl D x- <br /> ;� # (DRAW PLOT PLAN ON SE SIDE} <br /> E rc FOR DEPARTMENT USE ONLY <br /> 1.t <br /> PHASE I !+ �i D - �^ <br /> APPLICATION ACCEPTEby�BY C. <br /> DATE <br /> ' ADDITIONAL COMMENTS: PHASE IIT/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE �` <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br /> V " IAIA - - <br />