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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FI{.; 0_Fk��CE USE; 1601 E. Hazelton Ave. , Stockton, Calif. Z z..l -G[- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.7- 9,3dk/ <br /> y f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-36- 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/LOCATIONO O + /2 T l �d /►I YANSUS TRACT <br /> s f I <br /> Owner's Name �}�/,it�.�L ;F.G�/ _ Phon !7- 7 -� <br /> o l <br /> Address p & 4� City <br /> ' Contractor's Name License # /Z �tT /_?hone <br /> 64 67d <br /> TYPE OF WORK ChTELL <br /> NEW WELL¢' DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> .Mp I*rcAT3N f- PIMP--&PrPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIGiTANK SEWER LINES O() PIT PRIVY <br /> SEW &P'©SAL FIELD CESSPOOL/SEEPAGE FIT OTHER <br /> PROP E.RT&..LfNE - PRIMATE DOMESTIC WELL PUBLIC DOMESTIC WELL ..0 <br /> INTENDED�USE X401 1 TYPO OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial ! Cable Tool Dia. of Well Excavation Q <br /> Domestic/private 11 Drilled Dia.. of Well Casing <br /> Domestic public, _ ,Driven Gauge of Casing 160 <br /> Irrigation 'g r"�..: Gravelil' cic Depth of Grout Seal <br /> _ CathodiZ,.r t c.tion I Rota yea Type of Grout <br /> Disposal � � „"" Other Other Information <br /> "Geophysical fi) Surface Seal Installed B <br /> PUMP INSTALLATION: ContractorAAA <br /> A � Type'"of_Ruinp [.� ry" H.P. r�/Rn <br /> PUMP REPLACEMENT-; State .Work-Done�,.__..._ -. <br /> PUMP ` S t to Wo k Done <br /> ` + 1' k <br /> D S-TRUCTION OF WELL•+ I'Well Diameter Approximate Depth ?6 <br /> _ Describe Material and Procedure fr <br /> I hereby agree to comply with-a'7.1. laws and regulations of the San Joaquin Local Health District <br /> and the State of jCalifornia pertain iij to-dr--regulating l"1-'cofiYtru'c.td:on.: With nw.FlFTEEN"DAIS <br /> after completion[of my work an 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 .well in use.. The above <br /> information is tiue to 'the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION` <br /> PRIOR TO GROUTING,: AND A' INkL INSPECTION. <br /> SIGNED ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEi <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� '1� <br /> APPLICATION ACCEPTED BY1 6/� DATE `7 / <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE I ROUT INSPECTION ' P11A,E_jPI,FINAj1, INSPECTI N <br /> INSPECTION B DATE /i 7 INSPECTION BY DATE 2 L� <br /> IImoi' <br /> F H ,L�?Fi Ratr- _7C� /�//�/7� NCS G ,v , /��� <br />