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FO _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :. (209) 466-6781 <br /> APPLICATION FOR WELL°CONSTRUCTION OR PUMP PERMIT Permit No. 7� 3 4&-)IM - 9a9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED te pez�2_,,7�.7,7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fo CAN:VNt onstruct <br /> PP Y q , <br /> and/or install the work herein described. This application is made in compliancerwith San Joaquin <br /> 4 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local ,Health District. <br /> i. JOB ADDRESS/LOCATION 31 r-r 1 ' Aw CENSUS TRACT <br /> it <br /> Owners Name MAY V61 Phone <br /> Address City <br /> Contractor's Name S License Ago� Phll6neZJ() <br /> TYPE OF WORK (Check) : NEW WELL r DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7,, <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I�/7 <br /> µ Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES {^-PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE'"PRIVATE DOMESTIC WELL5WY_ PUBLIC DOMESTIC ;WELL •"®" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial r Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing : <br /> Irrigation Gravel Pack Depth of Grout Seal '01 <br /> Cathodic Protection XRotary Type of Grout ' ' <br /> Disposal Other Other Information 7M <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor lojoor 4W,it s <br /> Type of Pump '� H.P. i----- <br /> PUMPS REPLACEMENT: / / State Work Done 1 <br /> IPUMP 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 we11 ''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. 11 The above <br /> i' information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> JPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ITLE ./ may► _ _iiE <br /> 0 PLOT PTAN, ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T _ <br /> 'APPLICATION ACCEPTED BY � DATE <br /> 1 ADDITIONAL COMMENTS: - _ . f �` r <br /> k PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> ' INSPECTION BY DATE INSPECTION BY ���1-'��„� DATE <br /> �r <br /> y � tea . <br /> H 1426 ���� 2M. <br /> �zEv. x=74 _ _� <br />