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� juliquill DIS1*eCT <br /> FOF. OFFICE USE: / 1601 E. Hazelton Ave. , tockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;5;7 "a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4.110 $ NE ccs TONT/ A D CENSUS TRACT <br /> owner's Name Z7,�:-j?l2 N l C& Phone <br /> Address lal0 A/f' UZQ& JR 0 City S 7- <br /> Contractor's Name SS <br /> _ License 112G.S7(o/ Phone4lL4'-7, �T <br /> _ e _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENTff <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TkNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia. of Well Excavation pC <br /> _y Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> it PUMP INSTALLATION: Contractor <br /> Type of Pump liizH.P. / <br /> • PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: % / State Work Done <br /> i, ` 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 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 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 l�yc '�{• ��-_. - <br /> (DRAW�T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY S - DATE �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE :2 <br /> CALL I'OX A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 11 1426 5/711M <br />