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SAN JOAQUIN LOCAL HEALTH DISTRICT `" - <br /> FO 0 ; . iSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . W .Teldphone: '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7icJ <br /> THIS PERMIT. EXPIRES 'l YEAR FROM,DATE ISSUED Date Issued <br /> '7 .S i, S Glit(to-Ir&t A� (Complete In.Triplicate.) y¢- L) 253--- 17-0-05 <br /> � <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 /> - i <br /> JOB ADDRESS/LOCATION, 5 � � .,j�'ea or 2_r.4C% g-:,4Z ,,,::r�CENSUS TRACT' <br /> Owner's Name x Phone 63S--90400. <br /> Addreds ?�_ u�. �� �� - City EG <br /> Contractor's Name a License � , ��� Phone " - F <br /> TYPE OF WORK (Check): NEW WELL f� DEEPEN '/� RECONDITION /� DESTRUCTION f� <br /> PUMP IN LATION / / PUNP REPAIR /� PUMP REPLACEMENT { <br /> 0 her <br /> -,&Yx <br /> DISTANCEOTO NEAREST: SEPTIC TANK-.:f SEWER LINES ;�/� ' PIT PRIVY <br /> X SEWAGE DISPO AL FIELD CE SPOOL/SEEPAGE PIT. OTHER <br /> sPROPERTY LINE - PRIVATE DOMESTIC WELL LL <br /> INTENDED USE TYPE OFY.WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ,S"/ . 6` <br /> Domestic/private ` Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge-of Casing ----- i <br /> Irrigation t Gravel Pack Depth of Grout Seal -�- <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information ' st� <br /> Geophysical Surface Seal Installed By; ear <br /> PUMP INSTALLATION:, Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR. . S_tate:Work_Done: x`51 <br />, DESTRUCTION OF WELL:: Well. Diameter Approximate Depth <br /> �- Describe Material .and Procedute <br /> Y 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. I WILL CALL FOR A "GROUT INSPECTION <br /> IPRIOR TOG UTING AN A MAL INSP ION s <br /> SIGNED J 5. TITLE <br /> (DRAW T PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -ne-0 F.P DA : 1 -.30.-7,G <br />` ADDITIONAL COMMENTS: c� fit <br /> -PHASE II RKUT INSPACTMN a7 fltl PHASE III INAL INSPECTION V <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1? H I1x2Fi Rr�er_ 7-94 f! h/-75 .2M._. _ <br />