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_ N JOAQUIN LOCAL HEALTH DISTRIC-- <br /> F01; OrVICE USE: 160!'E. Hazelton Ave. , Stockton, Ca..tf.. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued4;/6.-2/ <br /> (Complete In Triplicate) — - <br /> '.pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaqui <br /> lounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> TOB ADDRESS/LOCATION P `I .>/-Piye-cam/ — _ CENSUS TRACT <br /> A✓ner's Namei, /, v y,, /� cr, --_ -- Phone <br /> 'address /�/ 7 S�• . �'� _��+! C U 1.�� City <br /> :ontractor's Name 1/-1// /�� ,, ,j��,//i.••r �c>, License # ySyy6GrbPhone <br /> AA A_&A S 0 1/I C_ <br /> ''YPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> )ISTANCE TO NE_;REST: SEPTIC TANK ZS— SEWER LINES I L 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 2 }y_ <br /> Domestic/private Drilled Dia. of Well Casing 6 " <br /> Domestic/public Driven Gauge of Casing fSi <br /> Irrigation ,X Gravel Pack Depth of Grout Seal ,S-o F r" <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information c <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <7 '- H.P. <br /> PUMP REPLACEMENT: / / 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 District <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 District <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 owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE ' ON. <br /> SIGNED TITLE <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �• DAVE <br /> ADDITIONAL COMLfENTS: �. <br /> PHASE GROUT INSPECTION PHASE FINAL SPECTION <br /> INSPECTION BY llAT'. ~- -• AISPHGT'ItiN''BY _x/77 <br /> ,Q7 211 <br />