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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. SCAMWED <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,9-Ll 961 <br /> THIS PERMIT EXPIRES 1 YEAR FROM' DATE ,ISSUED Date Issued L�_Z6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or instar, 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 ,Pe i+rl.� �/ OV klel-Ve A* L4o' CENSUS TRACT <br /> r <br /> k Owner's Name Da r ✓ QIV d1l& di <br /> Address L k s+ City L® 4 j, <br /> Contractor's Name_ �, ,' rod ee t LLi y License #42hhone f-��s— <br /> ,.. T <br /> TYPE OF WORK (Check): NEW_ WELL /'.7 3EPEN;f� RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR /� PUMP REPLAGEMENT <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 i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k Industrial Cable Tool Dia. of Well Excavation A- 9' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing _ /p <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Cathodic Protection Rotary Type of Grout 1p�'�e� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY:`&M G-mass° <br /> PUMP INSTALLATION: Contractor 4. LL-V- r+es"y z <br /> Type ,of Pump <br /> PUMP .REPLACEMENT: / / State Work Done <br /> f PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> µ Describe Material and Procedure <br /> r I Sereby 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,'knoowledge and belief,_,I_WILI._CALL.FQR A GROUT INSPECTION <br /> PRIOR TO GROUT <br /> NG D A, FINAL I PE <br /> . SIGNED sy.�• TITLE x <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C., DATE <br /> rADDITIONAL COMMENTS: <br /> } PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION .BY DATE_ _ .;,,„_,,,,.INSPECTION-BYE_ -=-=-.-DATE <br /> 9 } [ <br /> E:.H-1426 RPV. 1-7& _. h/75 2M } <br />