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SAN JOAQUI LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE;__ ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1.71 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 8!� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-,E-27 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaquin' <br /> C unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION „ �(� CENSUS TRACT <br /> Owner's Name 11"D6hI r5p1 S6 ) Phone <br /> f� I <br /> Address V �(� Y T city �S �&66 ) " <br /> Contractor's Name LARK W�[L It License # �i�a�2-Phone 7-STV # <br /> TYPE OF WORKCheck) : NEW WELL/ DEEPEN N%/ RECONDITIO _ <br /> ( _ _/ / DESTRUCTION /-7 <br /> PUMP INST LATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 V' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEW LINES �4- PIT PRIVY �! <br /> SEWAGE DISPOSPL—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 / <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing #to _ ! <br /> -Irrigation , Gravel Pack Depth ofNGrout Seal <br /> Cathodic Protection r„✓ Rotary -Typ'e of Grout C!FUC J� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br />�PUMP :•REPAIR:---=--- ---� %/-�State"Work.°�Dorie" �' <br /> ��' r -O�y�v , <br /> DESTRUCTION OF WELL. ?Well iameter Approximate epo'A <br /> j,Des.cribe, Material and Procedure <br /> I hereby agree to comply with all-vlaws 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 complefion 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 /> informati s true to the best of my knowledge and belief'.' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 TING JWMA F . 1,NSPECTION. <br /> SIGNED ! --- TITLE '►� r <br /> (DRAW .PLO.T PLAN ON REVERSE SIDE) —�— <br /> �/ h� FOR•DEPARTMENT USE ONLY <br /> PHASE I �•:+ <br /> APPLICATION ACCEPTED .BY DATE <br /> "• 4 <br /> i - <br /> ADDITIONAL COMMENTS: { Ale� <br /> MWI II ,GR UT INSP a PHASE III/ NAL INSPECTION <br /> INSPECTION BYW <br /> ZC "J WIN®S�PECTION BY Q DATE - .1 <br /> E H 1426 Ra r "l 7 <br />