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SAN JBAQUIN LOCAL HEALTH DISTRICT <br /> � FOR`,OFFICE USE: 1601 E. Hazelton Ave: Stockton Calif. <br /> Telephone: (209)' 466-6781 <br /> A111-I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. LIO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-22-7? <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. 1862 and the Rules and Regulations of the .§ n Local Health District. <br /> JOB ADDRESS/LOCATION tL'.& %tCH sit E.1: IID ; 0 t'U ` IIVt ISUS TRACT <br /> Owner's Name r;':,I J I Uj I.. . Phone 334-0753 <br /> 53 <br /> Address X016 „ f.t ,.i6lti:'U'N` RD. City LORI <br /> Contractor's Na �` `' License 290 Phon <br /> Y <br /> .:r <br /> TYPE OF WORK (Check) : �q _ DEEPEN/-7 RECONDITION/- DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER JO "'40� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,0 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.*,of Well Excavation 201, <br /> Domestic/private Drilled Dia.= of Well Casing <br /> Dourest �blic Driven Gauge of Casing ,; <br /> .. ; ck Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informations ,a -.0 7,11=0 <br /> Geophysical S..uzf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type' of Pump. , H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter s Approximate Depth <br /> Describe Material and Procedure,, <br /> I hereby agrod to `cbmply with all laws and regulatio a San Joaquin Local Health District <br /> and the State of California pertaining to or regulatifgpwe l ''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 ki�PORT •of the Welland notify them before putting the .well in use. The above ". <br /> informatio ' is true to the bes',,,f,my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 6ROUTING AND A FINAL INSPECTION <br /> SIGNED 4' ; : t.n BFIQ8 BX 5��. Az��&4 <br /> TITLE u3! . <br /> (DRAW PLOT PL ON REVERSE SIDE) <br /> FOR DRPAR1rrMF.WT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR NSPECTION PHAS III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E <br /> 77 ! 2M <br /> H 14 6 Rev. 1-7 m:, .... <br /> 1 f <br />