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SAN JOAQUTN LOCAL HEALTH- DISTRICT C01.4�ro�ii�17 <br /> FOR '.OFFICE USE: ' 1601 E. Hazelton.Ave. , ,Stockton, Calif. F <br /> L. �77 Telephone : (209) 466--6781 <br /> 'M APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is 'Aereby made to the� San Joaquin Local Health District for a permit to construct. <br /> and/or install the work herein described. This application ismade in compliance with San Joaquin` <br /> County4Ordinance d- <br /> -No. 1862 and- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 12 3L/2L S Ike h r cQ _ CENSUS TRACT S �/ <br /> 4 <br /> Owner's Name Uj m` �, a-A-c/ ..SQ '-I Phone <br /> Address City gSGe;L_ <br /> Contractor's Name 'rAd, .License # Phone : <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 �] <br /> " F PUMP. INSTALLATION ,PUMP REPAIR / / PUMP REPLACEMENT /-7 �4s <br /> u. Other /7/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 f <br /> Domestic/private. Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing c? <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information i , <br /> 4F Geophysical ` Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor J aka >S la-V3 PU Yrs <br /> Type. of Pump �� b n, e (e_ H.P. . <br /> PUMP `yREPLACEMENT: / / S tate Work Done <br /> PUS -REP ~-�'"�'• � 8'tate Work Done '�,e.�r�-�e%. /� ��d��P ���owi✓.�2 /�-- <br /> i <br /> ES-TRUCTION OF WELL Wel.`l-�Diame-ter, Approximate Depth J <br /> Describe Material and Procedure E <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 thein 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 INSPECTION <br /> PRIOR TO GRQUTING AND A F AL INSPECTION. <br /> SIGNED C. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ROUT INSPECTIO PHASE /FIN INSPECTIO <br /> INSPECTION BY ATE INSPECTION BY DATE / /;2 7 <br /> F H� vL� <br /> 162h Po _ 7-7 � 2 <br />