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,QA SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—r Zi'l ICE USF.. 1601 E. Hazelton Ave. , Stockton, Calif. ,4 <br /> Telephone: (209) 466-6781 <br /> - - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. ' J' (D g 7Aj <br /> 16q P, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �.Z3 <br /> (Complete In Triplicate) <br /> Application i, 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 Sant Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB A DRESS/LOCATION g0_71C . MOSAIC- L,4425 CENSUS TRACT <br /> r <br /> Owner's Name ©/U 1+91LL6<,. Phone <br /> Address �74" / .- ��/�-/�N� L/�Il/ - Citytp1' i <br /> •3 <br /> Contractor's NameAILicense # 1/Idyl Phonej6Ac E <br /> TYPE OF WORK (Check): NEW WELL / 1 DEEPEN / / RECONDITION / /. DESTRUCTION /7 <br /> PUMP INSTALLATION PC"MP REPAIR / PUMP REPLACEMENT /-7 <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY d <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT. OTHER ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1/ Cable Tool Dia. of Well Excavation <br /> =jDomestic/private Drilled- Dia. of Well Casing <br /> =Domestic/public ' D-liven Gauge of Casing �. '+ Jtq• _�._ <br /> rrigation Gravel Pack Depth of-Grout Seals ►� l7.S <br /> Other Rotary Type-of Grouts Uk <br /> �. Ot•her'.- Other,-Iriformation ' <br /> PUMP INSTALLATION: Contr1 .actoz �• =_ <br /> Type of,Pump ` H:.P. <br /> PUMP REPLACEMENT: i / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DFRTRUCTION 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 pertai.ning.'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 /> 14ELL DRILLERS REPORT of the well and notify them before putting the we 11 in use. The above <br /> information is true to the best of my knowledge and belief. <br />"i SIGNED ` TITLE �/ R <br /> 717 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I ,f <br /> APPLICATION ACCEPTED .BY / DATE -1,2- — - 2--? <br /> J ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE .2 7--�7. INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />