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SAN JOAQUIN LOCAL ITMALTH DISTRICT <br /> FOk OFFTC-E USE: ) 1601 E. Hazelton Ave. , Stockton., Calif e, <br /> --{ <br /> Tele hohei <br /> P (209) 456-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION•`OIC PUMP PERMIT Permit No.-7Z,.-_5_) <br /> THIS PERMIT EXPIRES. HEAR FROM DATE,'I'SSUED ; Date-Issued L6 :2-7-1- <br /> (Complete In`Triplica•t"e) <br /> Application`id,hereby~ de-to the San Joequin, L'ocal'.'H9alth District for,:Atpermit to construct <br /> and/or install the work herein described. This apPI cation is made incompliance with San Joaquin <br /> County Ordinance No: 1862--and .the Ruled`arid Regulations 'of the Safi oa ui. " ocal Health Dist <br /> !ll � <br /> JOB ADDRESS/LOCATION S Ed 7 CENSUS TRACT <br /> Owner's:Name` 4 «j , Aw <br /> Phone <br /> Address. . . <br /> - - - - <br /> .. . City ,- <br /> contractor's <br /> ity Contractor's Name � D . <br /> r.�.a/._....�. T,icense !t ,26S7G/ Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DPEPtX,/_7 RECONDITION /_� DESTRUCTION /_7 <br /> s <br /> PUMP IN f% P REpAYR /-7 PUMP REPLACEMENT rrT <br /> Other <br /> DISTANCE' TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> INTENDED—USE ' .. .. TYPE OF WELLCONSTIRUCTION SPECIFICATIONS. <br /> Industrial _ : Cable Tool Dia. of Well Excavation <br /> �� - Domestic/private -- - <br /> Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge' of Casing_ <br /> Irrigation <br /> Gravel Pack Depth of Grout eal _--... <br /> Other Rotary Type Of Grout ti <br /> �_- <br /> Other other, Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . . S.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completiori of. my work on a new well; I will furnish the San Joaquin Local Health District a <br /> WELL DRILLER REPORT of the well and notify them before putting the well in use. The above <br /> information s t. ue to the best of my,knowledge and belief. <br /> SIGNED _ TITLE <br /> DRAW PLOT PLAN ON_ -REVERSE SIDE <br /> FOR DEPA "NT USE ONLY <br /> PHASE I 01 <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROAT INSPECTION PHASE II NAL-INSPECTION, <br />" INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ 1M `i <br />