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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFS OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. PP'' <br /> Telephone : (2091) 466-6781 <br /> APPLICATION FOR WELLCONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued L2� � <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 San Joaquin Local Health District. <br /> JOB /LOCATION ENSUS TRACT <br /> AOwner's Name et y'NLj Ir (�1C N OLL-LI,0-07 Phone <br /> Address City ` <br /> Contractor's Name y (r(/ License ��`Phone ", -32 <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN DESTRUCTION /_7 <br /> _ <br /> f r PUMP INST CATION / PUMP REPAIR f / PUMP REPLACEMENT /-7 <br />{ <br /> Other <br /> DISTANCE TO NEAREST: -SEPTIC TAN +-SEWER LINES rPIT PRIVY <br /> SEWAGE`DISPOSAL MELD CESSPOOL/SEEPAGE- PITJ��OTHER r <br /> PROPERTY L NI E —iIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia..,of Well Excavation <br /> Domestic/pfivate Drilled Dia. of-Wel-1 Casing <br /> r <br /> i Gauge y- <br /> Domestic/public __ Driven ' 3. ge of Casing <br /> IrrigationGr•avel Pack IN Depth of Grout Seal <br /> Cathodic Protection Rotary -.. Type3of Grout <br /> Disposal Other _,Other Information, <br /> Geophy►"sical' Surface--Seal Installed By:— <br /> PUMP <br /> :PUMP INSTALLATION: Contractor Q 9 71~k s '` <br /> Type of Pump s ` H.P. <br /> 1 PUMP REPLACEMENT: / / ._ State.Work Done <br /> PUMP .REPAIR*,x State ggWork .Done <br /> 4 1 � . ' �" ty'j • <br /> DESTRUCTION OF WELL: Well"Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 41 hereby agree to comply with all laws .and regulations of the, San Joaquin Local Health District <br /> and the State of California pertaining`tIa'or.,regulating wel:1`68`nstruction. 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 arid notify them before putting the well in use. The above <br /> information-is true to the best ofxmy knowledge and belief. h WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGIAND A FINAL INSPECTION. <br /> SIGNED ' <br /> { TLE J � <br /> a h ► ( W PLO L N REVERSE SIDE) <br /> FOR D P TMENT USE ONLY <br /> , PHASE I <br /> 1�217XZ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS _I G UT INSPECTIp PHASE JAI/,FINAL INSPECeL <br /> ; INSPECTION BY - DATE ( INSPECTION BY 4 7 DATE <br /> ) 117 21M4 <br /> R H ILM Pow- 1-74 U . <br />