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9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601r,,. Hazelton Ave. , Stockton, Cal.,, . <br /> Telephone: (209) 466-6781 yg <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./J� // <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-,30,78 <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 13652 EL-r MRIPOSA a?O4A CENSUS TRACT <br /> Fr <br /> z.Name ARV <br /> z Ol 1&_� FIz. Phone - 5Z <br /> Address 1191 j AL WIV {.f}.OE 11 City �ro�lC7"oiy <br /> Contractor's Name L �1` L L C E UlPff yr � License #766Q Phone <br /> TYPE OF WORK (Check) : NEW WELL IvT� DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �- <br /> f QS - 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 /> Indust al Cable Tool Dia, of Well Excavation ' <br /> stic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing dk/Z <br /> Irrigation 1 Pack Depth of Grout Seal ' <br /> Cathodic ProtectionRotary Type of Grout C r F <br /> Disposal Other Other Information <br /> Geophysical Surfece Seal Installed By: <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 DiameterApproximate Depth <br /> Describe Material and Procedure' <br /> I hereby agree to comply with ally laws and regulations of the San Joaquin Local Health District <br /> and the St of Ca ornia pertaining._to or_ regulating_well_-cons true4ion. Within FIFTEEN DAYS <br /> after co le of <br /> of my work on anew we4, I will furnish the San Joaquin Local Health District a <br /> WELL DRI LER REPO o the wel and n fy them before putting the well in use. The above <br /> informa 'on 's tru to he e £ my owledge and belief. I WILL L F R A GRO INSPECTION <br /> 'RIOR TING D N s CT <br /> SIGNED TITLE <br /> ( RAW PLOT PLAN. ON REVERSE SIDE). _ __ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY a 11 DATE -76 7,? INSPECTION BY DATE Z 6 - <br /> E H 1426 uo.. i_7A 1177 21 <br />