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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 41-,24/- <br /> I (Complete In Triplicate) <br /> }he <br /> I Application is reby "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 Joa <br /> County Ordinance No 1P62 and the Rules and Regulati'on's) of the San Joaquin Local Health Distri <br /> i JOB ADDRESS/LOCATION lS ►111 S. 6 honk to A rni L9 nk jQCkj0NG CENSUS TRACT <br /> Owner's Name�ONY S'ILVA` F SONS mwfJ y Phone <br /> ! Address �RQO �,l tj AC,IC MNE RQ City Qrnmpo <br /> Contractor's Name �IWn 'PC)MP License._ I(�[x/n3� Phone-7Z-7-55L <br /> .. .7 ra-'_ <br /> ! TYPE OF WORK (Check) : NEW WELL/� DEEPEN / / RECONDITION /7 DESTRUCTION /_ ] <br /> f PUMP 'INSTALLATION /PUMP REPAIR /—/—PUMP •REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES^ PIT PRIVY~ <br /> SEWAGE DISPOSAI 'FIELD CESSPOOL/SEEPAGE OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL _ <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 1� Industrial f Cable'Tool Dia. of Well Excavation <br /> (, <br /> Domestic/private I Drilled ;: Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing , i <br /> I Irrigation " Gravel Pdck'_`Depth of`GrouteSeal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal +( Other Other Information <br /> Geophysical hf Surface Seal Ihstalled By: <br /> 111 t <br /> PUMP INSTALLATION: Contractor Ce)c9F4AR1tilC -P( ) <br /> Typelof Pump hjS (,)Lnn gtj-,Fn L)n WL•P. 3Q� <br /> PUMP REPLACEMENT: / / (State Work Done f <br /> II t _ <br /> , PUMP .REPAIR: / / State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and-regulations of`the San Joaquin Local Health bistri <br /> and-the State of California pertaining to or regulating well construction. Within FIFTEEN DA' <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri <br /> ( WELL DRILLERS REPORT of the'well and notify them before putting the well in use. The above <br /> - information ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI( <br /> PRIOR TO G G 49D A FINAL INSPECTION. <br /> SIGNEDja <br /> TITLE G�Aml1�3/i <br /> - tit (DRAW PLOT PLAN ON REVERSE SIDS) ' 0 <br /> 'f y OR DEPARTMEIJT USE ONLY <br /> ' PHASE I\APPLICAED /I <br /> TION ACCEPTBY 1' - DATE <br /> 'ADDITIONAL'COMMENTS: <br /> PHASE. II ,GROUT.:4NSPECTION PHASE III/FINAL INSPEC�T-I,O�N�� <br /> SPECTION BY i DATE INSPECTION BY DATEs- <br /> e-r CLt"B <br />