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4 JOAQUIN .LOCAL HEALTH DISTRIC It J <br /> FOE OFFICE USE: 160. . Hazelton Ave. , Stockton, Calf. /�'� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77/kl�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distf a o construct <br /> and/or install the work herein described. This application is d izcop : c with San Joaquin <br /> County Ordinance No. 862 and the Regulations of the Rules and Re a <br /> g n �aquxn Local Health- District. <br /> ,rfG� dk 1 tv es 7' V 14G or- Tt b ew7v-nl . <br /> JOB ADDRESS/LOCATION /2pra4> Sows r! ooc- 9200 -4. Rv�9M CENSUS TRACT <br /> Owner's Name Phone -7 75— <br /> Address �. 7. N t !-{o te.0 CitySo <br /> Contractor's Name (Division of San Joaquin 5uip'ur Co.) License # :310378 Phone 362-9 7 <br /> Rol' ZA"Sponme <br /> i TYPE OF WORK (Check.) : NEW WELL / / DEEPEN/ / RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS X <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well. Casing {r+ <br /> Domestic/public Driven Gauge of Casing <br />€ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Y YP <br /> Cathodic Protection Rotary Type of Grout <br />� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> i <br /> PUMP INSTALLATION: Contractor <br />! Type of Pump H.P. . <br /> PUMP REPLACEMENT: /tate 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 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 S ➢ f K &T LF SPECTION <br /> PRIOR TO GR09TJ4G AND A FIN L I S 0 _ (Division of San loograin iu!p:ur co') <br /> SIGNED TITLE Ill ?J_ Sncrnai2nP <br /> o St <br /> RAW LOT PLAN ON REVERSE SIDE) aauni - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION u I PHASE III/FINAL INSPECTION '211 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F u ii,9ti 0 <br /> n .. ��. <br /> 77 - 2M <br />