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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f .- Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7-F1.9,4d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedR-71 <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 lg2b ��� �1 IJJ/Q,D CENSUS TRACT <br /> f �} Phone <br /> Owner's Name LYRC p )�fnf <br /> Address 20 S MAM Rh4_b__ __ City <br /> Contractor's Name 61AU WAt to _f(J)P, LU License #16602, Phone <br /> r TYPE OF WORK (Check) : NEW WE (DEEPEN / / RECONDITION / L DESTRUCTION../� <br /> PUMP INST; ATION / PUMP REPAIR / PUMP REPLACEMENT <br /> Other / / •» . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE ,PIT -----­OTHER ` <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC .WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> fJadustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing '"'}--- `o <br /> Domestic/pub.lic�- - Driven .. Gauge-of Casing,:. _ �- rw <br /> I Irrigation G vel Pack Depth of Grout Seal r <br /> j Cathodic Protection Rotary` Type of Grdut_1 <br /> Disposal Other, Other Information <br /> Geophysical '" .��` � s Surface Seal. Installed 'B : <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump �- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP .REPAIR: / / State Work Done u <br /> DESTRUCTION OF WELL: Well Diameter k Approximate Depth <br /> iDescribe Material and Procedure <br /> Is of the San Joaquin Local Health District <br /> I hereby agree to comply with all laws and regulation q <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 /> 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 A GROUT: INSPECTION <br /> PRIOR TO GROUTING AND A FIN& INSPECTION. f <br /> SIGNE TITLE ��- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: Q <br /> PWPO GRO INSPECTI PHASE I I/FIN INSPECTION <br /> INSPECTION BY DATE S� _ INSPECTION BY / :FIs LATE $-3 �`� <br /> l_7G 1G7h 7 <br /> �� 7 - . <br />� �. i-1 iso,. �� �� � � <br />