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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. ' <br /> Telephone: (209) 466--6781 ✓ �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.; ` <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-jo.;28 <br /> (Complete In Triplicate) <br /> Application is hereby made to,the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescribed. 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. 0 <br /> JOB ADDRESS/LOCATION 7 L. - Sr M R I POS A R0�- CENSUS TRACT <br /> Owner's NameHARV_ X14 `I O CE F Phone cal- 1sL� <br /> Address 1191 t�R��W�� ��1NE City <br /> 1 <br /> Contractor's Name t L L t" Q u1i>f1EVr License it 6 6 6 L Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/V DEEPEN /_/ RECONDITION DESTRUCTION /_7; <br /> PUMP INSTALLATION / / PUMP REPAIR' /—/_PUMP REPLACEMENT Y-7Other <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1j)5"_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "w <br /> Indus t" "aI"""'"""'"" Cable Tao1 Dia, of Well Excavation' <br /> stic/private Drilled Dia, of Well Casing " u <br /> Domestic/public i Driven Gauge of Casing _ #'�Z <br /> Irrigation "°"'< C 1 Pack Depth of Grout Seal !� <br /> Cathodic Protection I Rotary a,. .-i;°,Type of Grout CF <br /> Disposal .1 Other :_ . Other Information ? <br /> Geophysical i� �_Surx_ace Seal Installed 'By: ! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - y_ . . - - HtP,- <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done` , <br /> DESTRUCTION OF WELL: Well Diameter �� ,. l w <br /> _ Approximate Depth <br /> Describe Material and Procedure--,, <br /> I hereby agree to comply with all-,,la*s and regulations of the San Joaquin Local Health District <br /> and the State of Ca ornia pertaining to o.r-r.egulating-we-1J.-';constxu.rtt-on. Within FIFTEEN DAYS <br /> after co 1e ion of my work on a ew we , I will furnish the San Joaquin Local Health District a <br /> WELL DRI LER REPO o the wel and n ; "fy them before putting the well in use.. The above <br /> informa "ora, s tru to he e f my owledge and belief. I WILT. LL F R A GROWINSPECT ON <br /> PRIOR TING D N L S DWE CT <br /> SIGNED TITLE k <br /> _.--...--...__(DRAW_P.LOT.._PLAN-.ON_.REVERSE-SIDE)_ <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I �/?al_7e APPLICATION ACCEPTED BY �_ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4:;;, DATE & <br />