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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> FW'OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 .E SoyJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,: 'Date Issued 5- <br /> (Complete <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 herein described. This appXication' 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 c- . CENSUS TRACT <br /> Owner's Name 6 Li R ms " Phone ���:7066 � <br /> { <br /> Address C200 0/ Ci <br /> S' <br /> _ _ t <br /> Contractor's NameA, .. <br /> .1 License C2290/l1 Phone <br /> 1 <br /> TYPE OF WORK- (Check): NEW WELL /7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION -( PUMP REPAIR -/� PUMP REPLACEMENT /7 <br /> Other <br /> tw i o c Lv Tri+ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL'/SEEPAGE-PIT `—OTHtR-_' m t <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL R5 <br /> INTENDED USE TYPE OF WELL (CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of iWell. Excavation <br /> Domestic/private Drilled Dia. of :Weil Casing i <br /> Domestic/public Driven Gauge. of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection RotaryType of Grout �I <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> \�{ <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump _a��T % , .,.. H.P. / <br /> r) <br /> PUMP REPLACEMENT / / State Work Done t <br /> PUMP .REPAIR: J -,/ / State Work Done' <br /> DESTRUCTION OF WELL: Well Diameter TM-~ -� Approximate Depth <br /> Describe Material and Procedure 1 t a t <br /> I hereby agree to,comply,wi.th. all laws -and-regulations--of,-the San Joaquin Local Health District <br /> and the State of California pertainingrfo�or regulating well '-cons 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.-yell in'.use... .The above i ' <br /> information is true to-the-best-of- my. knowledge and belief I WILL CALL FOR A GROUT INSPECTION' # <br /> PRIOR TO G10IMG 'AND 4 VjUt INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> P94PEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPT <br /> IL4L-11vonDATE / , <br /> ADDITIONAL CONN ENT S: i <br /> PHASE II GROUT -INSPECTION PHAS I INSPECT N F <br /> INSPECTION BY DATE INSPECTION BY DATE <br />