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d(/ 1z'" <br /> k �F,0 . SAS JQAQUIN LOCAL HEALTH DISTn_,,. <br /> OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. FILE C.O' PY <br /> r Telephone: (209) 466--6781 <br /> f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7,7- V0 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ? r2 �.7j <br /> M <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 wade in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION 11733 N,. Davin Rd CENSUS TRACT <br /> Owner's NameLouis LXX Rabugir_ Phone <br /> Address" 1312 W.Oak St City Dodi <br /> Contractor's lame Domestic Service License # 114455 Phone 36$--4004 <br /> TYPE OF WORK (Check) : NEW WELL / at DEEPEN/ f RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other I <br /> DISTANCE TO NEAREST:' SEPTIC TkvK 70 SEWER LINES 75' PIT PRIVY <br /> .SEWAGE DISPOSAL FIELD 75' CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well. Excavation 1211 <br /> _ x Domestic/private Drilled Dia. of Well Casing $ <br /> tT— <br /> Domestic/public Driven Gauge of Casing 12Ga <br /> ` Irrigation Gravel Pack Depth of Grout Seal 4Z1 <br /> Other Rotary Type of Grout Sand .& ' cement <br /> Other Other Information <br /> PUP INSTALLATION: Contractor Domestic Service {� <br /> Type of Pump 511ersjble _ H.P. 3H.P <br /> PUMP REPLACEMENT: / / State Work Done j <br /> PUMP UPAIR: / / State Work Done <br /> DFGTRUCTION 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 thel 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 ; <br /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is ue t�the .,best of my knowledge and belief. <br /> SIGNED `' TITLE Owmer <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _. _ DATE — 7 : <br /> ADDITIONAL COMIMENTS: <br /> PHAS II GROUT INSPECTION PHASE -III/FINAL INSPECTION <br /> INSPECTION BY DATE 7- 7 INSPECTION BY � DATE -/ <br /> C4L1 FOR A .GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> [�/711m <br />