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j. � SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR. FROMADATE 'ISSUED Date Issued l 2-O, 7 L <br /> (Complete In Triplicate) <br /> Application is ,hereby made. to .the,.San;Joaquin Local Health District for a permit to construct �f <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 San Joaquin Local Health District. <br /> :: t . <br /> JOB ADDRESS/LOCATION (ld' l 0.A CENSUS TRACT _ } <br /> Owner`s Name �1 ��F �"���r,Q,�� Phone <br /> City ! D�rotCCL t <br /> Address _ M 1- b <br /> { Phone <br /> ��� ' <br /> Contractor's Name License� � - - <br />-0-TYPE O1(Gheck) : NEW WELL DEEPEN '// / RECONDITION /_� <br /> F ORK DESTRUCTION '/� <br /> v �< PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEARESTr:t_. SEPTIC TANK SEWER LINES PIT PRIVY <br /> ,SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT OTHER <br /> INTENDED USET)T +0'-.WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialy�A C#le Tool Dia. of Well Excavation <br /> Domestic/pr _4ate 1 W..'� .Drilled Dia. of Well Casing _ k, <br /> Domestic/public CL Driven Gauge of Casing +J <br /> Irrigation i Gravel Pack Depth of Grout Seal H <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 4! # <br /> PUMP INSTALLATION: ` Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F7 State Work Done <br /> PUMP REPAIR: / / State Work Done T <br /> DESTRUCTION 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 t <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 /> E 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 /> SIGNED. TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR EPART N USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I/F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE �2 O <br /> k CALL FOR A GROUT INSPECT16N PRIOR TO GROUTING AND FINAL INSPECTION. <br /> k E_k' 14 2b _. �_. . 4172 1M _ <br />