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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO: FFICEUSE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. R91110 <br /> ,THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED- Date Issued 10-7 <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 Rxiles and Regulations of the San Joaquin Local Health District,. <br /> JOB ADDRESS/LOCATION /Y._„ t;J �{ _ _ _ CENSUS TRACT <br /> - _- <br /> Owner's Name � Phone <br /> A <br /> Address. C) A2 6hG JV City . . <br /> w. Contractor's Name License # j*2�, Phone .676 <br /> TYPE OF WORK (Check): NEW WELL '/_ DEEPEN '/? RECONDITION I_7 DESTRUCTION f7 <br /> -77 <br />! PUMP INSTALLATION ,C/ PUMP REPAIR -/ PUMP REPLACEMENT I T <br /> f Othetj I / <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 iTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial +i Cable Tool Dia. of Well. Excavation (� <br /> Domestic/private Drilled Dia. of Well Casing [ <br /> Domestic/public Driven Gains of Casing <br /> Irrigation Gravel Pack... Depth',"of Grout Seal {�j <br /> Cathodic Protection I = Rotary,.. Type of--Grout 7 C <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed. By: _ <br /> ' <br /> PUMP INSTALLATION: Contractor _ <br /> Type f of .Pump H.P. - <br /> PUMP : - / 1 State Work Done zig ,. � /V 0. <br /> PUMP ,REPAIR: / / State Work Done <br /> � o <br /> RES�TRUCTION OF WELL: Well. Diameter Approximate 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 /> k 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. know dge an a ef. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO°S G.'AND A FINAL INSPECTiO <br /> SIGNED <br /> <. joF JVRAW L T PLAN ON REV . SE SIDE) <br /> -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY KDATE 4Z::;_d:�Z) <br /> ADDITIONAL COMMENTS: t <br /> PHASE II d3 0 " S CTWN PHA F AL ISPECTI N <br /> INSPECTION BY - - ATE INSPECTION ATE . <br /> R N 149A uo, - 1_94 ! - —..__ _- 4115 2M _, <br />