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'-'`SAID JOAQUIN LOCAL HEALTH DISTRICT <br /> FFD&;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76' 7 9L7V <br /> i <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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,Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> y JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ►� pr! f 1 C �- N'S Phone g o2 LS <br /> Address a L/ LvN 2 <br /> • City `__ <br /> Contractor's Name . k <br /> 0�.�I� t,J - .I .L_ _` 'E ,�r `! License #Q2/oS Phone S� 9;77 <br /> f: <br /> -TYP.E�OF-WORK -(Check): NEW-;WELL=} DEEPEN /7-� RECONDITION_/_7-�`DESTRUCTION`/77 <br /> PUMP INSTALLATION / PUMP REPAIR 1-7 PUMP REPLACEMENT /' <br /> r Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -7-� SM <br /> RLINES SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE AF WALL CONSTRUCTION SPECIFICATIONS <br /> Industrial; Cable Tool Dia. of Well Excavation eg q < <br /> Domestic/private Drilled,,.. Dia. of Well Casing "4,. <br /> Domestic/public Driven .Gauge of Casing - y <br /> X 'Irrigation Gravel Pack" Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal- Other Other Information ' <br /> Geophysical Surface Seal Installed B : <br /> IMP INSTALLATION: ` . <br /> Contractor /-�U 1�J.x W L �-� <br /> . Type .of `Pump .- ._ H.P. SU <br /> PUMP REPLACEMENT: / / State Work ,Done <br /> PUMP .REPAIR: / / State Work:Done <br /> I';�.DESZRUCTION,OF .WELL: Well.-Diameter--� - ,- _ a-.>—AP-P_roxizftat e 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 CALL -FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A FINAL INSPECTION. <br /> SIGNED K TITLE <br /> (DRAW PLOT PLAN ON .REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. P II FIN INSPECT 0 , <br /> INSPECTION BY DATE INSPECTION BY HATE <br /> , H4`2E`- `Rev. 1-7 4 ���.,u <br />