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/ :'`N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: VVV 160.x . Fazelton Ave. , Stockton, Calms Al f t fJ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76. 37a al <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-2-u-29 <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 Loc 1 TX ietrict. <br /> JOB ADDRESS�O AT N OLTtI - SUt <br /> ff�� <br /> ✓ <br /> Owner's Name 461 7�[ip+�}P��a oQ y� / l / Phone <br /> Address �Id, o7-3 CoA. �//(� /1> f / KLL• City 44121—j <br /> Contractor's Name Kp`/pLy.p��&_Ahl. ��{2CPj�t2 �n 1 >, License # ayj.3 PPh7one <br /> TYPE OF WORK (Check) : NEW WELL 1-�K DEEPEN / / RECONDITION /-/- DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK LfRj�� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS WO <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4(2S v <br /> Domestic/public Driven Gauge of Casing A2 61-7 4 <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout L \„ <br /> Disposal Other Other Information _ \V <br /> Geophysical Surface Seal Installed B : �(w1 <br /> PUMP INSTALLATION: Contractor <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 Depth <br /> Describe Material and Procedure <br /> I nereby 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 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 belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTINGAND A F AL INS C7IO <br /> SIGNED14 C4 <br /> jDRAW/jFLOT PkAN ON REE TLEV V' <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA,SE II GROUT INSPECTIOT P III/ NAL INSPECTION <br /> QINSPECTION BY J-, ATE <br /> DATE S <br /> INSPECTION BYAea <br /> r 2- ATE <br /> DD <br /> F. 14 IL,7fi R.v, 7-74 O ��-�- <br />