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�`/►" SAN JOAt}UIN LOCAL�H DISTRICT <br /> i3O£. OFFICE USE: = 1601. E. Hazelton Ave: , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S- <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 hereiTr described. ` This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local. Health District. <br /> O <br /> .TOB ADDRESS/LOCATION _ -QQ 't/ o�. Scr.�i$ SUS TRACT <br /> Owner's Name Phone 6� A'. 6/ 76 <br /> Address d t46 -K14L / ' - — —� City _ <br /> Contractor's Name License # I/g 3 Phone j4Z_d j?!V <br /> TYPE OF WORK (Check) : NEW WELL L1 DEEPEN '/—/ RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION J PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> p - Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY pp <br /> SEWAGE DISPOSAL` FIELD_ CESSPOOL/SEEPAGE PIT OTHER j <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool � Dia. of Well Excavation /0 ", <br /> Domestic/private Drilled,.. Dia. of Well Casing; 'r <br /> Domestic/public Driven RIN Gauge of Casing /.I.. <br /> Irrigation 'Gravel. Pack Depth of Grout Seal' !- <br /> _' Qi <br /> Other ___)�,'4Rotary Type of Grout ,. ti. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor a !` <br /> Type of Pump -+ H.P. <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> PUMP 'ZEkIR: / / State Work Done <br /> .DFCTRUCT12N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 %jell '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 well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ` TITLE .+ <br /> (DRAW-MOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE S �f 172- <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION P % I I/FINAL INSPECTION <br /> INSPECTION BY s DATE INSPECTION BY DATE 6,76 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 1i/7'11 m <br />