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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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 '�� <br /> (Complete In Triplicate) Zo3 _ 2-00-2-7 <br /> , <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 /> Gty <br /> JOB ADDRESS/LOCATIONrzr 4- CENSUS TRACT <br /> Owner's Name a tfnlx- _ Phone bg/]s <br /> Address A/ s, AL4 if id City 5C� AI-161t <br /> Contractor's NameAAIK,�2License #-3 //y Phoned/ - / <br /> TYPE-OF-WORK (CH—eck) —_NE_W WELXAL <br /> DEEPEN / / RECONDITION / / DESTRUCTIONPUMP INSATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> ' i <br /> DISTANCE TO NEAREST: SEPTIC TANK ,5nQ - SEWER LINES:d PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ___--. OTHER <br /> PROPERTY LIN TRIVATE DOMESTIC WELL-221�' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE_ OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �( <br /> Domestic/private _ Drilled Dia, of Well Casing 'i " 4� <br /> Domestic/public Driven Gauge of Casing <br />�X Irrigation Gravel Pack Depth of Grout Seal du �--- op <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information N <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ("'jv RGt"�, to e e"" '7' <br /> Type of Pump _7_"- .� H.P. p <br /> PUMP REPLACEMENT: / / State Work Done 6/11/-?a <br /> PUMP .REPAIR; State Work Done <br />)ES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> 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 work on a new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL DRILLERS REPORT of the well and noti them before putting the- well in use.. The above <br /> information is true to the b s o mywledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO AN A FIN I <br /> SIGNED TITLE <br /> t I <br /> RAW PLOT PLAN ON REVERSE SIDE) LJj <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: (117 <br /> PHASE II GROUT INSPECTION PHAS II/FINAL INSPECTION <br /> INSPECTION BY .DATE #AINSPECTION BY DATE �' <br /> 1177 u�l4r <br />