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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OFFICE USE: L 1601 E. Hazelton Ave. , Stockton, Calif. _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27-921 IJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ff-2,L_? <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. 1862 and the Rules and Regulations of the San Joaquin Local .Health District. .I <br /> JOB ADDRESS/LOCATION 7r Sb{,,[ -1 hof CENSUS TRACT <br /> Owner's Name AANi 0 L-LI(T-Z_ bri-ST Puk CT-1 Phone QC/Zr 6 <br /> Address d U SO LLT 1-A. F P6(+b City 'Ak <br /> r <br /> Contractor's Name V L ASL K .WELL �(�L41 mry � ,license # C,pW Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTOLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 g <br /> Other- ./_/ ...,. .._. �..... .�—_ . _ _ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER L-INES r PIT PRIVY <br /> SEWAGE DISPOSEFIELD "`"'CES OOL/SEEPAGE PITS ; OTHER ; <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4) <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATI-ONS <br /> Dndustrial Cable Tool Dia. of Well. Excavation <br /> omestic/private Drilled "bia, of Well Casing ( " <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigationrave l Pack Depth of Grout Seal . ° � s <br /> Cathodic Protection r�Rotary Type of Grouti �/Tl1LBy-— <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed BY: <br /> 0 L <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP-REPAIR:z-""_ '..."'"/"�/"Sate'Work➢one" ��..- a.-» ,:� _�;.�- .� .. r <br /> PES-TRUCTION 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 completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of e well and notify them before putting the..well in use. The above V <br /> information is true tLy <br /> est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T-OL, MUTING F14A1 WPECTION. p <br /> SIGNS ' - - - - __ __ TITLE--t:lf�'L/�xk a[-� --^r--,..�- � <br /> (DRAW PLOT PLAN ON._REVERSE SIDE) h <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS,111I GROTWT INSPECTION PHASEdTj1j/FINbL INSPECTIO <br /> INSPECTIFON BY DATE INSPECTION BY* DATE <br /> E .H,:1426 V <br /> Rev. 1-7.4 1f/7 2M <br />