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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IFO " FFICE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Te ,phone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7���Z �T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -","7"'dlll" <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 Tand Regulations of the San Joaquin Local Health District. <br /> G� <br /> JOB ADDRESS/LOCATION Z63 /V. /`/�(�yNr/r 67 e S'CENSUS TRA <br /> Owner's Name GcOi_',tac �V _ Phone •7S / - 3C0'� I <br /> Address --PO -601f 167 CY.LGAAECA-A- qs•iZ y <br /> _ cit t <br /> Contractor's Name 6AMI WFLG Dlzf 1.IA(C-) License e;i ZP Phone16y--3317 <br /> _-- Te Ra 3 .0C,L -- <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMI.' REPLACEMENT / 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEIjf PIVY <br /> SEWAGE DISPOSAL FIELD �— CESSP001./SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL .� <br /> s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation i•b" IrS T $� <br /> Domestic/private Drilled Dia, of Weil Casing �" <br /> Domestic/public Driven Gauge of Casing 7 <br /> {I Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout( A <br /> _Disonsal Other _ Other Information <br /> Geophysical Surface Seal Installed Dv: ,� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / 1 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materi rd Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Lo L Health Distric! <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY§ <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 UTINC 4ND A FL NSPECTION. -rte <br /> SIGNED �'f� N �a.a-.1 TITLE Az& � <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,� r �7 <br /> APPLICATION ACCEPTED BY �_;Lai! Zez 7i4 e �� DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION '/—T PHASE III FINAL INSPECTION <br /> DATE - y 7- 9'S INSPECTION BY P✓ DATE—? ,x 7 1 s' <br /> INSPECTION BY G --- "�- <br /> 0!77 2M <br /> E 11 1426 Rev. 1-74 <br />