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cq� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �S <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 7-1--37.7-- <br /> THIS <br /> .37yTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /O ,;;:�7 <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 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 CENSUS TRACT <br /> Owner's Name �L <br /> I'u VIA L2611 AL Phone 2739- _ <br /> Address m <br /> City c"elllllor✓ <br /> Contractor's Name �,� License ltb2rAjd Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION; <br /> ALRECONDITION',/-/ DESTRUCTION/_7 _ <br /> PUMP INSTLATION 1� PUMP REPAIR / / PUMP REPLACEMENT <br /> Other _.A�Se'ALk-n- 0� I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -c *SEWAGE DISPOSAL �FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY �LINE-'- PRl-VATt DOMESTIC WELL PUBLIC DOMESTIC WELL € <br /> - INTEI USE P.E_,OF--WELL_.,_..__, ~ CONSTRUCTION SPECIFICATIONS . <br /> Industrial . Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven *.�.•: j Gauge of Casing <br /> Irrigation Gravel Pacfe Depth of Grout Seal i <br /> Cathodic Protection -.,Rotary Type of Grout <br /> Disposal Other"` Other Information 4 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor // ,�� ; `�_,�• <br /> Type of Pump i <br /> YP p '4- 9 f H.P. <br /> PUMP REPLACEMENT: / / State Work Done A <br /> PUMP .REPAIR: / / FState Work Done } <br /> DESTRUCTION OF WELL: /���11 Diameter Approximate Depth <br /> 1�0IlJescribe Material and Procedure <br /> 1�V_44py_ i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <br /> and the Stare 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 DRILLERS REPORT of the well and notify them before puttingthe well in use.. The above <br /> information is true to the best of. my knowledge and belief. -1 WILL C FOR GROUT INSPECTION <br /> PRIOR TO GMNG AND ArjFIN,4rL INSPECTION. <br /> SIGNED TITLE { <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> } <br /> PHASE II GROUT INSPECTION f1UkWjII/FI1jAL INSPECTION <br /> INSPECTION BY _ DATE _ INSPECTION BY DATE <br /> i- %-7x.1.0 �Yna /1 ` <br />