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SAN JOAQUIN LOCAL HEALTH DISTRICT �L <br /> FOk OFFICE USE: Stockton Calif. <br /> 160.1 E. Hazelton Ave. , <br /> Telephone : (209) 466--6781 Permit No. '7�j <br /> APPLICATION FOR WELL CONSTRUCTION OK PUMP PERMIT -71 ,1 , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��" ✓ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin i5olDistrict <br /> made inrcompliancea permit twithnSanu <br /> ct <br /> isJoaquin <br /> and/or install the work herein described. application <br /> County ordinance No. 1862 and+the Rules and Regulations of the San Joaquin Local Health District. <br /> �C t,� CENSUS TRACT <br /> JOB ADDRESS/LOCATION t� J--- <br /> 1 <br /> ,,�� �'1 4 2173` � <br /> Owner's Name let L L I'I M %, Phone ; <br /> Address L`f � �RSFf rnf P, Sur. <br /> City S C1 <br /> License # Phone : 7 –3 J 11"1 <br /> Contractor's Name ( hfe� ---- <br /> 1 <br /> DESTRUCTION /7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / <br /> PUMP INSTALLATION / PUMP ,REPAIR / / PUMP REPLACEMENT /VI <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK� SEWERiLINES PTT PRIVY <br /> C SEWAGE DISPOSAL FIELD a4 .CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIV'ATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> I E <br /> NDED USE TYPE QF WELL CONSTRUCTION SPECTFICATIONS <br /> ndstri.al Cable Tool_ Dia. of Well Excavation <br /> Drilled ; -Dia. of Well Casing <br /> Domestic/private - Gau e of Casing <br /> Domestic/public t Driven g <br /> Irrigation I Gravel–Rack Depth of Grout Seal <br /> Type of Grout <br /> Cathodic Protection ! Rotary <br /> Disposal Other <br /> Other Information <br /> .., "- � <br /> Geophysical . .- Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ A.p. <br /> Type ,of Pump G <br /> PLACEMENT: State Work Done/ / --- <br /> PUMP RE T <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> f 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 /> WELL DRILLERS REPORT of the well and notify them before putting.rthe well in use. The above <br /> information is true to the best of my knowledge and belief . I VI�LL CALF FOR A GROUT INSPECTION <br /> 4h <br /> j PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE D�✓yI E'er <br /> SIGNEDf � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR�DEPARTMENT"USE`ONLY <br /> PHASE I DATE `D <br /> APPLICATION ACCEPTED BY 4 ' <br /> ADDITIONAL COMMENTS: T ��. –pS TI -/FINAL INSPECTION <br /> PHAS.E�.Ij OUT-INSRECTION- — " INSPECTION BY DATE <br /> 'INSPECTION BY DATE <br /> . _ b/77 _ 214 <br />