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t -- G/o SAN JOA LOCAL T <br /> FOE�'OEFICE USE: x601 E., HQUIN CAL HEALTH DISTRICT <br /> azelton Ave. , Stockton, Calif.. <br /> '-- Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s-- <br /> THIS <br /> S=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 District for a pexis to construct <br /> and/or install the work herein described. Thin application is made in compliance with San Joaquin <br /> County Ordi,nence No. 1862 and the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/Lb ATION. 'Z arfk �ri2'' CENSUS TRACT <br /> Owners Name _—���1�i!x ' 1� Phone r 1 f <br /> "Address tali �, _.. <br /> • City, <br /> Contractor's Name -- ,�IY 6__. <br /> License !! =S gG Phone { A V y-YIV <br /> -TYPE OF WORK (Check): NEW WELL '/�bEEPEN J-7 r . RECONDITION /'T DESTRUCTION % �• <br /> PUMP INSTALLATION ,g' PUMP REPAIR /7 PUMP REPLACEMEWT 17 <br /> Other /7 <br /> DISTANCE TO NEAREST': SEPTIC TANK 7 * SEWER LINES pIT PRIVY <br /> SEWAGE bYSPOSAi. IF LD CESSPOOL/SEEPAGE PIT OTHER W <br /> .� _... RAPEP_M LINE - PitIVATE STIC WELL�`� PUBLIC DOMESTIC i,F�LL- - - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS w <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> ✓Ifomestic/private: Drilled Dia. of Well Casing <br /> - -.—Xomestic/public.-- w --Driven ,.�Gauge-of-Casin$_, -' rrigution . :=----Gravel Pack Depth of Grout Seal - <br /> �_ Cathodic Protection- otarGrout* ------�-� ---- <br /> Disposal,; �:..- "� y Type of <br /> Other Other Information <br /> Geophysics]. - <br /> �.._. - Surface Seal Installed E3y:. ?L!� <br /> PUMP INSTALLATIONt Contractor <br /> A yps of Putap <br /> PUMP <br /> 1P10EM NT /L �/ S tateTarl� D me <br /> ,StcAtn Work Bone <br /> L,3�5�TRUCTIO�i^qF•WEL�a -- Well."Diam�tex <br /> A.pproFjmate Depth _ <br /> DescribeN\ <br /> � <br /> I hereby agree' Ln coippl.ywritEa gll laws grid x,•a$Rtalr�t io�T ne of• hlie Sm;� ;YaacEuin't.o�a� HeaXtk3 1ji.st r cr <br /> and the State of.California Pertaining to or regulating well ronstruetioxx. W1.thin k'I1r"TEI�FI I)L�XS <br /> after COMOXet:ioxt of my work on a newr well, I waill fuxnitsh the SaxA Joaquin Local in- FIV EmiDisI AYS tx <br /> WELT, DRIiaT,EEa;3 REPORT of :has well and notify thenk'before putting.the..we;l.l, in..use.. The' above <br /> i.nfarmation is true to the•beat•, of, my.knawledga and belief ' I WILL CSL x�O.R'A'A 'GROUT !NSPE;CJ'l:Oi.. <br /> MOR M GROUTING AND A FINAL INSPECTION. �--�-- <br /> STGNEDVITLE <br /> .� � DRAW PST PLAN a�sE: �xDi✓ ----_.— <br /> PHASE x FOR, DEPARTMENT.USE ONLY y �" <br /> . �. <br /> APPLICATION ACCEPTED BY � 1)ATI: <br /> A1lDxTxONAY, COMMENTS: <br /> _PHASE IZ GROUT INSPEET7_­­,___-­­—P _.--_..., <br /> INSPECTION <br /> PEIASE Il:�i�Ii�AL xNSPECxION <br /> INSPECTION. 0Y .r.c � ...m4DATF <br /> alb Rev. <br /> 4 2M <br />