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F <br /> SAN JOAQUIN LOCA, HEALTH DISTRICT MA-11 To ®&JWn <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 72-3 )lot <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /'/Q -7) <br /> �� (Complete In Triplicate) <br /> Application is here y made to the San Joaquin Local Health DAstrict 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 /> JOB ADDRESS/LOCATION Q`ZO/ 9 S� ., Ayeoeg- AP CENSUS TRACT <br /> Owner's Name Zo 4&1L7 12 GC ,,o+N c 46 Phone 3 7"7 <br /> Address 0!!E� 4�, / City <br /> Contractor's Name License # <.�'Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_`/ RECONDITION / / DESTRUCTION /-7AL _ <br /> PUMP INSTLATION PUMP REPAIR / / PITMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool . Dia. of Well Excavation Q ' <br /> . Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \, <br /> Cathodic Protection Rotary Type of Grout I" <br /> Disposal Other Other Information <br /> GeophysicalGeophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 42441-1 A✓-9 AZ <br /> Type of Pump sem_ c��' y� 't�v�' - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR•: / / State Work Done <br />' .DES'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 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 CAL4 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND 4 FIN INSPECTION. <br /> SIG NED —27 <br /> L'�C/ TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , DATE 0 <br /> Q- 7Z <br /> APPLICATION ACCEPTED BY — <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPEC r Ift "PHASE II/FINAL TNSPECTIPN <br /> INSPECTION BY DATE INSPECTION BY 7 ', �bATE // <br /> f <br /> E. H 1426 RPv. , 1-7L2M :,X <br />