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NA/L T A&AfyS <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> 'r Telephone: (209} ' 466-6781 <br /> 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) M-YS- 030.--!/ <br /> Application 4 by 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 Ordinance No. 1862 and the Rules and Regulations -thee Joa uin L cal Health District. <br /> JOB ADD ION �14G /g/�/Fy d Lam, CEN US TRACT <br /> Owner's'�Name /I ,0F_*/V Phone <br /> Addresslj �E 4/2ZCity <br /> Contractor's Namei✓l��� .C3i�oS i��L� GC] �iVL �� <br /> License # X7 Phone __1/ � �S-� 5� <br /> 1 <br /> TYPE OF-WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST ATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LO? PIT PRIVY (�1 <br /> SEWAGE DTSP SAL FIELn� 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 <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> D stic/public Driven Gauge of Casing 3 <br /> rrigation _Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection =Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : S'4 / <br /> PUMP INSTALLATION: Contractor <br /> Avte� <br /> Type of Pump/r ten. ..�- H.P. <br /> ke- <br /> PUMP REPLACEMENT: / / State 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO{,,GROU ING AND A F INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e <br /> APPLICATION ACCEPTED BY1,' 1P DATE /,g-.,2-7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTZ'7 <br /> . Y DATE 7 c�' <br /> � G G'�°'►fn Vi <br /> E H 1,426 1--7 4.Rev 2 1��7 ZM <br /> --- � J� 7 <br />