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Y- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 7�-1 lc! <br /> -------------- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In. Triplicate) 9 <br /> Application is hereby-made toithe 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. 4 <br /> C, L7 . 16CENSUS TRACT <br /> JOB ADDRESS/LOCATION `' c3 0� S ?o { <br /> r Phone 3647 Ca <br /> Owner's Name I <br /> I � I <br /> Address p #G�1-&/ c �d I� City G f} <br /> i , _ ,� C <br /> Contractor s Nates M 6'1oS�i _ License a' Phone dd ' -- <br /> �0"EL D 1 LL s Alm - -- . . <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/? RECONDITION / DESTRUCTION / 7 <br /> PUMP INST LATION -/ I PUMP REPAIR/� PUMP REPLACEMENT f7 <br /> Other 4/ / <br /> r; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _PIT PRIVY _ <br /> SEWAGEIDISPO5AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE IlOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r , <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection ~^ Rotary ' Type of Grout \a <br /> Disposal i Other i Other Information <br /> . <br /> -Geophysical Surface Seal Installed 'S <br /> y. <br /> PUMP INSTALLATION: Contractor 21 <br /> Type�'of Pump H.P. <br /> PUMP REPLACEMENT: m / / � 5tate Work Daae <br /> PUMP '.REPAIR: J /7 State Work Done <br /> k <br /> Approximate Depth <br /> DESTRUCTION OF WELL: - WelliDiameter <br /> k 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 worklon a new well,' I will furnish the .San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thejwell 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 /> 1 PRIOR TO GROUTING AND A IINAL INSPECTION. TITLE �= <br /> SIGNEDKVZ <br /> '(DRAW PLOT N REVERSE SIDE <br /> E EPARTMENT USE ONLY <br /> i .PHASE I DATE <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: PHASE _I F NAL INSPECTION <br /> P E I GROUT INSPECTION INSPECTION BY DATE <br /> f INSPECTION BY DATE 4 <br /> 2My w. <br /> sa a 11.9k ne.._ 1-7A <br />