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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> rEF1114­OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.® <br /> Telephone : (209) 466-6781 " <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE IT Pe o <br /> II <br /> 00 THXS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> Dla <br /> ate Issued J- - <br /> i 7_7 <br /> Application is hereby made t i the San (JoquineLocal In rHealth tDistrict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin <br /> Count' Ordinance No. 8'L 6 anthe RutI s�nd Regulations of the San Joaquin Local Health District. <br /> ION JOB ADDRESS/LOCAT ! 7 <br /> F <br /> s ! CENSUS TRACT <br /> j Owner's NameAAI L (� �[ <br /> E Phone <br /> Address / 0 17 1 C, <br /> City <br /> Contractor's Name <br /> r License 1yPhoneme <br />; TYPE OF WORK (Check) ; NEW WELLDEEPEN J RECONDITION / DESTRUCTION /_7PUMP INSTALLATIONPUMP REPAIR-/—/.—,PUMP <br /> - . REPLACEMENT /-7 <br /> f r � Other <br /> DIST CE TO NEAREST: SEPTIC TANK SEWER LINES : PIT P1�IVY <br /> . SEWAGE --DIFIELD CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTI-C WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �ustrial Cable Tool Dia. of Well Excavation } <br /> Bomestic/private 1 Drhled <br /> . _ _ - -...- di ,Dia. of Well Casing N <br /> Dome` icJpublic"'••`� �^"�° _ .�. .�.r�:4 _ g t" <br /> ens-��` ^►' Gaugeo "'Cas3ng' <br /> Irrigation I" Gravel 'Pack -Depth-- of Grout Seal <br /> Cathodic Protection Rotary F _ Type of Grout , 1 <br /> Disposal - Other Other Information ,L + J <br /> Geophysical <br /> Surface Seal Installed By: ' <br /> PUMP INSTALLATION: ,Contractor ! <br /> Type of Pu , <br /> H. <br /> PUMP REPLACEMENT: a <br /> State Wdrk Don/ e / R <br /> PUMP .REPAIR: a ��"/Lwl� Gu. <br /> State Work�.Done 7 <br /> 01 <br /> ES TRUCTION WELL: W 1All ameter <br /> escribe�Material and Procedure pProximateDepth /✓/� <br /> II hereb ! <br /> y gree to comply with all laws and regulations of the San Joaquin Local Health District <br /> after completion 6f my work on a new well, <br /> and the State of Galifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well 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'4.�`GROUT,`INSPECT ION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED z I <br /> f (DRAW PLOT -PLAN ON REVERSETLE SIDE) <br /> 1 <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I <br /> APPLICATION ACCEPTED "'BY� DATE C Q s <br /> WDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION , PHAS II/F NAL INSPECTION <br />[NSP_ECT,^I/ON BY DATE / ` b INSPECTION BY DATE <br /> 2 , <br /> -.E xIi 4 2:6: e.�i, _1=J 4 1 n .�. ry�: -7.'1 . "�' z 1�� � !" <br />