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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh*;OP'FIG-E USE: 1601 E. Hazelton Ave. , Stockton, Calif. '.--' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g-S 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-3/ -?7 <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. 'I862 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 7 [` CENSUS TRACT <br /> Owner's Name . 1) {� Phone _57-- �� <br /> Address /0-0f Ran v <br /> a_ 4 �{ City Tcy <br /> k. Contractor's Name Q.r�r[. �- —_I✓h� I /� _ License ����L�.�� Phone <br /> i <br /> TYPE;OF;,WORK_ Check) ; NEW-WELL . <br /> C ;DEEPEN /__/, „RECONDITION__/_77 <br /> , _DES-TRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /_7 i <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK �_ .SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD Y_ CESSPOOL/SEEPAGE PIT--- OTHER <br /> C PROPERTY LINE =PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL --- \ <br /> INTENDED USE TYPE- OF WELL �* CONSTRUCTION SPECIFICATIONS V. <br /> Industrial ,Cable Tool Dia. .of We117 Excavation i It <br /> Domestic/privateI3r-i.1Idd,�__. - __..Dia: of Well Casing " <br /> Domestic/public Driven Gauge of Casings <br /> IrrigationGravel Pack %_ t ,-Depth of Grout Seal <br /> Cathodic Protection Rotary { - - _ t <br /> ,�-- Type .of._.drout <br /> Disposal Other Other Information y <br /> —Geophys i cal ; <br /> r.,. � •_ _._.. -.,...,..,Su-rf-ace-Se-al Installed By: <br /> --._ -_-�_- .rr�._ M <br /> PUMP INSTALLATION: Contfactor �� r M b 3 5 - 7,g + �} <br /> ! Type--of—Pump V H:,p,1. <br /> PUMP REPLACEMENT: /,/ State;Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DES-TRUCTION` OFWELL: 'We11-Diameter � <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agiee ' 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 DAIS <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO. GROUTING AND A FINAL INSPECTION, <br /> SIGNER TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMEUSE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY ter. ATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III/ NAL INSPECTION <br /> INSPECTION BY DATE E TION BY TE <br /> E H 1 i` � "eev. 1- ayG� `' �Il�wr- r__.��_ <br />