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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOF,.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7g`- 21,Z <br /> 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 Joaquin' <br /> "County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI ,N ikxe US TRACT 4953F-030-3s . <br /> Owner's Name z Phone <br /> �\ a t <br /> , am <br /> Address A ti, <br /> j� <br /> Contractor's Name � <br /> License # /Pham , <br /> e i <br /> TYPE OF WORK (Check) : NEW WELL _/ DEEPEN %/ RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE PIT PRIVY ; + <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER ,f <br /> PROPERTY LINE - PRIVA DOMESTIC WELL PUBLIC DOMESTIC WELL I4 <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> dustrial able Tool Dia, of Well Excavation <br /> omestic/private 7 Drilled Dia, of Well Casing 151, `► + <br /> Domestic/public 1'. Driven Gauge, of, Casing &,jet_ <br /> Irrigation Gravel Pack Depth of Grout Seal T <br /> Cathodic Protection Rotary Type of Grout ! I <br /> Disposal , Other Other Information 11 ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> TYPe'of'}Pump__.. _ T. - - H.P_., <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: <br /> / / State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth "" <br /> Describe Material and Procedure <br /> k jDistri6q I hereby agree to comply with all, laws and regulations of the San JoaquinLocal Health and the State of California pertaining to or regulating well '�construction. Within FIFTafter completion of my work on a new well, I will furnish the San Joaquin Local Health <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is rue to the t of my knowledge and belief. I WILL C L FOR A 'GROUT INSPECTION <br /> PRIOR TO G U I AND FV" IN9P13CTION. / <br /> SIGNED / 1 TITLE "/ F } <br /> ' (D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEI I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 uA�,_ 7_74 1177 2M <br />