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91J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: V1601 E. Hazelton Ave.,; Stockton, Calif. <br /> ~° = Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- J31� <br /> 2�0 THIS PERMIT EXPIRES.1 YEAR FROM DATE ISSUED Date Issued J-�Lr?? <br /> '.S' ,�fn/ )4%E. (Complete In Triplicate) <br /> Application is tereb 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 Josquin <br /> County Ordinance No. 1862 'and the Rules and Regulations of the San Joaquin Local Health District. <br /> ® sejos <br /> JOB ADDRESS/LOCATION G/o vc,;I� 7-51,-(e- y/a /�/f e�ZCENSUS TRACT ' <br /> Owners Name Phone <br /> Address - ,!=2 ., r _ LJ a W1 - .02 O City _ A' <br /> Contractor's Name � ,�y - �°1y� � T 42&4111"v <br /> � License #2 ' at JPhone <br /> TYPE OF WORK (Check) : NEW WELL / . DEEPEN _/ RECONDITION /_7 DESTRUCTION ./] <br /> PUMP INSTALLATION PUMP, REPAIR / / PUMP REPLACEMENT [7 ! <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK r /, SEWER LINES YL 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 1� c. <br /> S <br /> irmestic/public riven Gauge of Casing <br /> rigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary,!" Type of Grout W <br /> Disposal Otlier`.� 'Other Information 4~ <br /> Geophysical Ky• Surface Seal Installed By: <br /> j <br /> PUMP INSTALLATION:- Contractor A - ' <br /> Type of Pump H.P. [� <br /> ti .01 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done "" T Y - <br /> z <br /> DESTRUCTION 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 AAYSfl) <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 �lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. -� , <br /> SIGNED f 01 TITLE -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPECTION PHASE FINa INSPECTION <br /> IPECTION -BY DATE INSPECTION BY Lam' DATE !z <br /> NS -7 7 <br /> E� u ,,.�� n_ , <br />