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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0� OFFICE USE: 1601 E. Hazelton Ave, <br /> Stockton Calif. ! <br /> Telephone: (209) 466-6781 permit No. 7l-l O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT (� <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ( " ��7 <br /> (Complete In Triplicate) rmit <br /> Application is hereby made to theSan <br /> Joaquin Localhis He alionDistrictmade furca pe ancetwithnSanuloaquin <br /> and/or install the work herein d <br /> County Ordinance No. 1.862 andithe Rules and Regulations of the' San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> iwo! Zd' CENSUS TRACT <br /> Q Phone J84 f-,2 <br /> � <br /> Owner's Name / <br /> City ec-p/v / <br /> 4 <br /> AddressD �• <br /> % <br /> LicensePhone <br /> Contractor's Name IleE r.i �o� l a ��?5 d <br /> TYPE OF WORK (Check) : NEW WELL /i'f DEE,PEN / / RECONDITION / P DESTRUCTION /-7I� <br /> PUMP INSTALLATION / / PUMP REPAIR / <br /> Other <br /> SEWER LINES 1 -)-4 PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK 11S �y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> i` PROPERTY LTNEiakPRTVATE DOMESTIC WELL jv; ,F1PUBLTC DOMESTIC WR L r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION S1'ECIFTCATIONS� L� <br /> 6 Cable Tool Dia. of Well Excavation 10, <br /> Industrial �/ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Domestic/public <br /> Drivo C� <br /> Irrigation Gravel Pack Depth of Grout Seal — <br /> T e of Grout <br /> Cathodic Protection _ Rotary <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> ok.0 <br /> Al o . <br /> PUMP INSTALLATION: Contractor H.P. <br /> `!w Type of Pump <br /> i <br /> PUMP REPLACEMENT: ;� State Work Done/ <br /> /�. / State.. Work Done" <br /> PUMP .REPAIR: _ � �,,... Y • � � �, <br /> Approximate Depth _ <br /> DESTRUCTION OF WELL- Well • "" <br /> s DescDiameter , <br /> 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"611'con5�ruc 'uin. Within FIFTEEN DAYS <br /> :wo'rk-on._a.-new-,well.,-�I-w.ill--.f.urnish-the-San Joaquin Local Health Distract <br /> after completion of i►yl <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nowledge ander\belief. I WILL CALL FOR A GROUT INSPECTION <br /> information is true to the. best of my k <br /> PRIOR TO GROUTING AND A FIAAL IN ECTION. TITLE <br /> SIGNED <br /> �- ------"'-'- (DRAW"PI;OT PLAN ON REVERSE STYE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I // DATE 9 <br /> APPLICATION ACCEPTED BY C/ <br /> F ADDITIONAL COMMENTS: PHASE JFINAL INSPECTION _ <br /> PI' GROU ; INSPECTION INSPCTION: BY ATE <br /> INSPECTION"BY <br /> 6,177 _ 2M <br />