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Rw� JOAQUIN IsOCAJ,„HEALTH DISTRICT <br /> _F0%­OFFICE E: 1601 E. Hazelton Ave. , •Stockton, Calif. r <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 _ _7 W� <br /> THIS PERMIT EXPIRES' I YEAR FROM DATE ISSUED Date Issued V- ;,- 7 <br /> ' (Complete In Triplicate) t <br /> Application is hereby made to the Sax: 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 Local. Health District. <br /> 11t'-o..0 Q^W t <br /> JOB ADDRESS/LOCATION'�ij`�����- �� '. Lf 1. � z 1 r,Q2d_- CENSUS TRACT <br /> Owner's Name - Phone - s <br /> Address City , Q P� <br /> Contractor's Name BL22 <br /> 5. i License #,2Z( 1 Phone_a?-�l�J. <br /> TYPE OF WORK (Check) : NEW WELL AaT I, DEEPEN /`/ RECONDITION /_7 DESTRUCTION /_] <br /> f PUMP INSTALLATION / / PUMP REPAIR'/ / PUMP REPLACEMENT -I_� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK AJOV SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD(/0 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 f <br /> Irrigation �_ Gravel Pack Depth of Grout Seal nehp <br /> Cathodic Protection X_.� Rotary Type of Grout <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> wit <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - V.P, <br /> PUMPLREPLACEMENT: / / State Work'Done <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. (strict <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' Distriet a <br /> TELL 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 INSPECTIQ.N <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SICKED -77 <br /> TITLE <br /> " DRAW PLOT PLAN ON ERSE SIDE �• <br /> DEP MENT USE ONLY <br /> PHASE iI = <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE 14 GROUT INSPECTION PHASE IFIYAL INSPECTION <br /> ' INSPECTION BY DATE 41 INSPECTION BY DATE <br /> T y <br /> �, ��• / :Z- <br /> 7117T .- <br /> -2H <br /> R eH 1426 Rau. 1-74 �Gr 4l x 71 T? <br />