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D <br /> 'Y <br /> SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> FOE7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 7 - 11001c) <br /> 7�- ,078I0 <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 /> unci/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/ ,96ffEeN.F � CENSUS TRACT <br /> Owner's Name AV,. Cro V) 4L Phone . <br /> Address <br /> sev net 4 city . . <br /> Contractor's NameAoor&24.471 42:1w License # '`` 2Phone ;� Zf a <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/7 RECONDITION/7 DESTRUCTION <br /> PUMP INST LATION / PUMP REPAIR/-7--PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANQSEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSARFIELD "'�"' CESSPOOL/SEEPAGE PITOTHER <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 1,2— It t^ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal_S"A r�Co <br /> Cathodic Protection Rotary Type of Grout e21401e/i - h <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: ContractorA4 06V-R4 <br /> ( /jjy A <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP {.REPAIR: / / State Work Done <br />, ,DESTRUCTION OF WELL: Well Diameter Approximate De th <br /> � Describe Material and Procedure r <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 /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1 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 TO .GROUTIN AND A PINAL INSPECTION. I� r <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ klN� �vim`-- DATE S <br />- ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS51XII FXNAL INSPECTIO <br /> INSPECTION BY DATE - INSPECTION BY DATE r' <br /> 17176 <br /> R R 1 A 7 A bo.. 1-171. L+ln /'.., �/.,_ 3x ��d Yv N w �y ""^ l 1 t/�7 9M <br />