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JOAQUIN LOCAL HEALTH DISTRIC,,W <br /> FOE OFFICE USE: 1601'E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No;746_1,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue41>.2a_7/o <br /> (Complete In Triplicate) <br /> pplication 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 Joaqui <br /> county Ordinance No. 1862 and the <br /> /Rules and Regulations of the San Joaquin Local Health District. <br /> "OB ADDRESS/LOCATION V ��/ (� ,Q lL Tot� /tCENSUS TRACT�s <br /> ;,mer's Name p�/�/ G� �CrL E V"/ <br /> / �J /�/ E� Phone / -ES8-2 / Z- <br /> Address O / - l/ /IV'e,4- City <br /> ntractor's Name �� �� //�(�/i S/-ld tz,: Jf CO License p Phone y6 Z <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN/_% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> wISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical Surface Seal Inssttalled By: <br /> JMP INSTALLATION: Contractor N'r =ifW�e�rjtn+ ' ( a <br /> NEw - Type of Pump Fig/L'89N/'S - H/c rSc <br /> " -JMP REPLACEMENT: / / State Work Done <br /> Me '.REPAIR: / / State Work Done <br /> j ;STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ..id 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 /> "?LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iformation is true to t best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> MIOR TO ANDiNAL INSPECTION. <br /> c?GNED ipfz TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PLICATION ACCEPTED BY /�"fis3 ��- DATE <br /> ,dDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> (SPECTION BY DATE INSPECTION BY DATE/ n <br />