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. CT <br /> ;OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� � • <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �e1 g7 V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-,;14 Z <br /> (Complete In Triplicate) <br /> Application is'hereby made to the San Joaquin Local Health 'District for s 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 /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name JLL!/9 �F—RIV TSI <br /> Phone 72-7 <br /> Address FP R60 <br /> City . . <br /> Contractor's Name <br /> /%(E License # Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/—f RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION J / PUMP REPAIR '/? PUMP REPLACEMENK7' <br /> Other /% <br /> i <br /> DISTANCE TO NEAREST: ` SEPTIC TALAR SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC,DOMESTIC WELL�� � A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Excavation <br /> Domestic/private .Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack-k � f <br /> Depth of Grout Seal. <br /> Cathodic Protection -Rotary Type of Grout <br /> Disposal - Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu <br /> MPJ <br /> H.P. . <br /> PUMP REPLACEMENT: / / State Work Done ~— <br /> PUNfPREPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter « r <br /> Approximate Depth 's --f- <br /> Describe Material and Procedure eU p F C Si/✓ ,6 ,' T4-0 t! <br /> 6I�OV - VIT IL.L C' Sfny �[ <br /> I hereby agree to comply with <br /> all laws and regulations of the San Joaquin Local Health District <br /> Ind 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting..the..well. in.use.... .The above <br /> Cnformation is true to-the.best of my,.knowledge and belief. I WILL CALL 'FOR 'A ,GROUT INSPECTION r <br />'RIOR TO GROUTING AND A FINAL INSPE ION. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />'HA5 E I <br /> F R.DEPARTNEN USE ONLY <br /> �� • <br /> AFP ICATION ACCEPT <br />►DDITIONAL COMMENTS: DATE , 2-2Q -,7.cl--�— <br /> PHASE II GROUT INSPECTION PHA F AL INSPECTID , <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE t <br /> tE If-14 Revue 1--7.4 -- <br />