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7145.9r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT.:01 F1'CE USI:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> R 'Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7V <br /> (Complete In Triplicate) <br /> Application is hereby �7ade 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 .1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,FOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's <br /> RACT -Owner s Name _ <br /> Phone <br /> .S6c���/.S OG�T�'1�� Cavr s^el�ofl�rn c ✓@�ia. aJo: /4/i NC'SIciJ IH v, <br /> Address Citye <br /> Conteractor'.s Name CccK License> /W 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL 't-gT DEEPEN/_/ RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION � Pt,'MP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other 'J / <br /> DISTANCE TO NEAREST: SEPTIC TANK 1&jo' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /5Z ' OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia, of Well Excavation _ /e <br /> Domestic/private f � Drilled Dia. of Well Casing r _ <br /> Domestic/public -- Driven Gauge of Casing /Z - <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> Other JCC: Rotary Type of Grout ' <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor /�l C/ <br /> Type o�f Pump -..�,�"7, ---H.P. . <br /> f <br /> PUMP REPLACEMENT: f / State Work Dane <br /> PUMP `kEPAIR: / / State Work .Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> A <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 REP T of the well and notify them before putting the well. in use. The above <br /> information is rue 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 <br /> APPLICATION ACCEPTED BY DATE -7 <br /> ADDITIC 'kL COZ,1MENTS: <br /> PITA E II QROUT INSPECTION PHAS III/FINAL INSPECT 0 <br /> INSPECTIOTvSY DATE 5 INSPECTION BY DATE ¢ <br /> CALL-VOR-A.GR&T INSPECTION -PRIOR.-TO GROUTING AND..FINAL INSPEC ION. <br /> E H 1126 5/731M <br />