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A-9 c T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� d <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED .Date Issued 1,-ICy-A <br /> 32LS..lIN.��- f-iv, (Complete In Triplicate) 228-030- L{Z <br /> Application 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 Joaquin <br /> County OrdinanceNo. 186,.2 and�the ules and Regulationgqblf the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �/ � � <br /> -&-qNSUS TRACT <br /> Owner's Name <br /> - - Phone <br /> Address f= <br /> Z� City�� " <br /> Contractor's Name <br /> Li n, �}'�, PhonF� �! <br /> wTYPE OF_WORK (Check}ti NEWsTnUCION_/.7 T `' <br /> - -'-_ - _ / /�`RECONDTTION_ <br /> OtMErINS%ALLATION / '/ PUMP REPAIR / / PUMP REPLACEMENT / / `� <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LI PIT PRIVY- <br /> SEWAGE DISPOSAL FIE L �'3 <br /> �1��-CESSPOOL/SEEPAGE PIT OTHER <br /> PRQPERTX LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION S' CIFICATIONS ✓ <br /> Industrial: "' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> 4-Irrigation ravel Pack Depth of Grout Seal <br /> Cathodic Protection otary Type of Grout <br /> , O <br /> Disposal Other <br /> Other Information <br /> Geophysical Surface Seal Installed.-B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> r� r, H.P. <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure \ Approximate Depth <br /> 'T <br /> I hereby agree to comply with all lawsand,regulations of. the San+Joaquin Local Health District <br /> and the State of California pertaining to olr 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 bes of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A FIN I PECT _ -- <br /> SIGNED TITLE <br /> (DRAW;PLOT PLAN ON 'REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT 'USE ONLY <br /> � �: � <br /> APPLICATION ACCEPTED`BY <br /> ADDITIONAL COMMENTS: DATE /-G-?8 <br /> PHASE GROUT INSPECTIONp� P SE II/FINAL INSPECTION <br /> INSPECTION BY ATE, -- f.� IN,S�PECTION BY DATE p g <br /> E H 1426 56 y' Il_74 <br />