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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. # i . <br /> Telephone:: <br /> P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -'111781 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 16-51 ,y ,, CENSUS TRACT 0 z' a <br /> Owners Name D0 NAL. � <br /> �, ` Phone �7� ®� <br /> Address GAJ i C, C� 1�i <br /> �{- City <br /> Contractor r s Name C_-- 1.- � U R License #76 Phone Z 7 I <br /> i <br /> TYPE OF WORK (Check):' NEW WELL /v' DEEPEN '/_/ RECONDITION / / DESTRUCTION /-7 �- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 I <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER`,LINES PIT PRIVY ----� <br /> �//��pp r SEWAGE DISPOSAL FIELD 120 CESSPOOL/SEEPAGE PIT `' OTHER -�- <br /> �f7ROPERTY LINE - PRIVATE DOMESTIC WELL �� PUBLIC DOMESTIC WELL �! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool fia.'iof Well Excayation 12 <br /> Domestic/private Drilled Dia. of Well Casing <br /> IrrigatioDomestic/n <br /> Driven �fGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal F <br /> i <br /> Cathodic Protection Rotary Type of Grout �� <br /> Disposal Other Other Information" <br /> wGeophys ical Surface Seal Installed -By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump w _ -H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work.:Done <br /> PUMP '.REPAIR: State Work Done R <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 DRILL REPORT of the well and notify them before putting the. well in use.. ' The above <br /> Znformat' n true o th be of my knowledge and belief. mI WILL C FOR A GROUT 'INSPECTION <br /> R <br /> To N A CTION. <br /> SIGNED TITLEA 9 <br /> "]� E <br /> W PLOT PLAN ON REVERSE SIDE) 0 i <br /> PHASE I ME <br /> FOR DEPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY DATE qL117 q/17FM <br /> ADDITIONAL COMMENTS: <br /> ,PHASE II GROTlT INSPECT ON PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY e ..� DATEL 3 A 9kS3 INSPECTION,BY- DATE <br /> r <br /> E H 1426 - 1177 � <br />