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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:;,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL,39471d <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 6- i6_,;�C, <br /> (Complete In Triplicate) <br /> Application is hereby md"de to the San Joaquin Local health District for a permit to construct <br /> and/or install the work herein described. This appXication is made in compliance with San Joaquin <br /> County `Ordinance No. .1862 and the Rules and Regulations of the San 'Joaqui.n Local Health District. <br /> ,TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ YAM1LeL LUZPhone eci0 <br /> Address k v , ,. L k 12 E City <br /> Contractor's Name -CIAP11r, ,/ /p C. License Li�GGz Phone <br /> �j <br /> TYPE OF WORK (Check) : NEW WELLfiy DEEPENfi- RECONDITION /_7 DESTRUCTION f T <br /> { PUMP INSTj!jATION REPAIR -/-7 ,,PUMP REPLACEMENT /-7 <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 <br /> Domestic/private Drilled Dia. -of Well Casing <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation ' <br /> & ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection )(' . Rotary Type of Grout p <br /> Disposal k. Other Other Information <br /> - Geophysical Surf�ace` Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT:'. / 1/ State Work Done ''e ,, s <br /> PUMP <br /> :REPAIR• - / / State Work Dane 4 . <br /> DESTRUCTION OF WELL: Well Diameter ' APproimate 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 Califor :ia' 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 thie-best-of- my-knowledge and belief—I I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR•UTING Akh A' FINAL I SPECTION. ' <br /> SIGNED OIZ&Z TITLE <br /> K (DRAW PLOT PLAN ON REVERSE SIDE) : <br /> _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT' INSPECTION <br /> INSPECTION :BYPHASE III FINAL INSPECTION <br /> fE <br /> 1: DATE a ' . INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />