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l <br /> f ., kd <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> _Fu_ &FACE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209 . 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7- p <br /> �' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -Issued <br /> ' � E (Complete In Triplicate) <br /> Application is bier y made todthe 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 Lo - 1SUS TRACT <br /> ��.Owner's Name x Phon <br /> E � <br /> .Address - City /Cr ... ... <br /> Contractor's NameEi2p lZe�i License �� '_3// �{ Phoey�-_� .5 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 . <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCETO' NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> 4 SEWAGE�DISPOSA.L FIELD CESSPOOL/SEEPAGE PIT OTH ��_ <br /> PROPERTY LINE -- PRIVATE -DOMESTIC WELL. PUBLIC DOME T,IC W LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPE-C, - INS } <br />` Industrial t Cable Tool Dia. of We11' Excavation /PZ L' p <br /> Domestic/private l Drilled + Dia. of Well Casing 1 " <br /> Domestic/public E Driven _'` Gauge of Casing <br />� flrrigation U Gravel Pack ; Depth of Grout Seal U\� <br /> Cathodic Frot <br /> mm . .t- . Rotary .� Type.,of Grout <br /> I` ion . <br /> Disposal Other Other Information. , ,. . , <br /> Geoptiysical` _ Surface' Seal Installed" <br /> PUMP INSTALLATION: Contractor _ 1 C,- <br /> Type of Pump17 c_ G 7.E..i' Gam-L� T H.P. <br /> �7 <br /> •� a <br />{ ah <br /> PUMP REPLACEMENT: / / State 'Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DE-SIRUCTION. OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f , <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 we11''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 /> West of y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> in.fprmation:. is true to the <br /> PRIOR T ING. AFI S ION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> E PHASE I ' <br /> ! APPLICATION ACCEPTED BY > DATE <br /> ; ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTIQN <br /> INSPECTION BY DATE /� INSPECTION BY�,J DATE ,2!7 <br /> - tf.77 2M <br /> kt <br /> 41r, <br /> u1 1.9 L n __ 1_7 A <br />