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C/ SAN JOAQUIN LOCAL HEALTH DISTRICT , -,-„ <br /> FOFi�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L./-�S�Lr1 <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED a e 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 /> 31aaz , <br /> JOB ADDRESS/LOCATION -3fi K c F_1__ _B CENSUS TRACT <br /> A <br /> Owner's Name Phoria <br /> � <br /> Address City . <br /> � <br /> Contractor's Name License #,Z0pWt/'Phone4f66.0&f-6 s <br /> TYPE OF WORK (Check) : NEW WELL '/ � R/_7DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT /]� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK E?O SEWER LINES 'yt PIT PRIVY <br /> SEWAGE DISPOSAL?FIELD/3 `^-k-CESSPOOL/SEEPAGE'PIT OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'_' PUBLIC DOMESTIC WELL # <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial. ' . jCable Tool Dia. of-Well Excavation : _ <br /> Domestic/private 'Drilled Dia:, of Well'Casing r <br /> Domestic/public jDriven Gauge,of Casing j b d =V <br /> Irrigation }Gravel Pack Depth'of Grout Se l 5-p' <br /> Cathodic Protecxion Rotary Type of Grout " <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : . . . <br /> PUMP INSTALLATION: Contractor <br /> 4� <br /> Type of Pump 7, H.P. ' <br /> PUMP REPLACEMENT /7 State Work Done <br /> PUMP '.REPAIR: / / State Work Done a _ I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and' Procedure <br /> g <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 /> after completion of my work on a new well, I ;iaill 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 aflmy..knowledge and belief. ` I WILL CALL FOR GROUT INSPECTION <br /> PECT <br /> PRIOR TOG IAL TO-GROUTING AND I SION. f <br /> SIGNED 'TITLE r <br /> DRAW PLOT PLAN ON REVERSE S,ID <br /> OR,DEP ARTMT USE ONLY <br /> PHASE I .J <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COMMENTS: g_ � <br /> PRASE II GROUT INSPECTION: j P I FIN INSPECTION <br /> INSPECTION BY ,. DATE 6 � 7� � INSPECTION BY DATE <br /> E R 1L24 1.h7e nu <br />