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DATE :21L-12,___ <br />PHASE /FIN INSPECTION <br />DATE7—___ZAL2Z— <br />INSPECTION BY INSPECTION <br />DATE <br />f PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHAS I <br />' INSPECTION BY <br />GROU <br />4 ;10: A .,11 14:011 /70f> • al <br />p. <br />,,n, •11,4.- • <br />..........411.......,:,•memmlin•Vdmr..../,•••••,••=. <br />SAN JOAQUIN.LOCAL.HEALTH DISTRICT <br />1601.E. Hazelton Ave,, ,Stockton, <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />Application is tereby <br />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 Ordinance No. ,1862 and the Rules and Regulations of the' San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION <br />Owner's Name <br />City . <br />riA.A.0.0.5:1-6rAid <br />Permit No. 2212,50 <br />Date Issued/.247 <br />made <br />3 CENSUS TRACT - <br />Phone 7 6? 3 2' 6— 3 <br />Address <br />Contractor's Name <br />TYPE OF WORK (Check): <br />DISTANCE TO NEAREST: <br />4611A/1_,T_Ltd_23_, 411)C7 J9 7103e <br />NEW WELL J DEEPEN 17 RECONDITION f—T DESTRUCTION 4q400)4-, <br />PUMP INSTALLATION / PUMP REPAIR / T.—PUMP REPLACEMENT I—T <br />Other 1/ <br />SEPTIC TANK , SEWER LINES ! PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITr- , poTHER 1 <br />PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' <br />::T <br />stic/private <br />Domestic/public <br />Irrigation <br /> Cathodic Protection <br />Disposal <br />Geophysical <br />ENDED USE <br />Industrial <br />Li TYPE OF WELL <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />.Dia.,of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Sealy <br />Type of GrOilt <br />Other InformatiOn <br />Surface Seal Installed <br />0-4V <br />CONSTRUCTION SPECIFICATIONS <br />License 14,2_ S7010 Phone EmZi2Me <br />• <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />PUMP .REPAIR: <br />DESTRUCTION OF WELL: <br />ontractor <br />Type of Pump <br />If State WOrk Done <br />// State Work Done <br />WelliDiameter <br />Describe Material and <br />Approximate Depth <br />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 RAYS <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 CALL FOR A GROUT INSPECTION <br />PRIOR TO GROUT <br />SIGNED <br />INC AND A FI AL IN PECTION. TITLE <br />, <br />I (DRAW PLOT PLAN ON REVERSE SIDE ,