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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> •. Telephone: (209) 466-6781 <br /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :zo M <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Y_/S <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 2aver A - 46s; CENSUS TRACT <br /> Owner's Name 1E,..__ /�s __.. _.,_.__,. _..., . . ._ .-•---.._. Phone <br /> Address Zq_' A2,eA 4udF City AVA <br /> Contractor's Name �P,_a� TL�L/-�.4 '/ License Phone537-326 2 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL J DEEPEN "/ / RE ONDITTON /_7 DESTRUCTION /_ I <br /> PUMP INSTALLATION 2R7 PUMP REPAIR / / PUMP REPLACEMENT /7 <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 /> Industrial Cable Tool .., Dia. of Well Excavation <br /> Domestic/private' Drilled ' Dia. of Well Casing <br /> Domes•tic/publie;. -Driven--- ;Gauge -of-CasingG\� <br /> Irrigationde g Gravel Pack Depth of Grout Seal �Q <br /> Cathodic Protection f/ Rotary Type of Grout A/r <br /> Disposal Other Other Information <br /> Geophysical Surface; Seal Installed By Cllr <br /> - - - -- -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu p AIVftM H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP �.REPAIR: / / State Work Done <br /> DES•TAUCTI N OF WE Diameter 01— 712-151-7 Approximate Depth <br /> escribe Material and Procedure <br /> Old we�G ��. � �J��� <br /> I hereby agree comply with all laws d regula ons of a San Joaquin Local ealih 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 the.-well in use.. The above <br /> information i ue to the est of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION _ <br /> PRIOR TO,,G T GAN INSPE ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br />, APPLICATION ACCEPTED B - DATE AZI <br /> — <br /> ADDITIONAL COMMENTS: 1 JI <br /> PHASE II G UT INSPECTION P S /FIN INSPECTI .N <br /> INSPECTION BY DATE -7`7 INSPECTION BYIAIADATEze Z-2 <br /> ' 1177 _ 2M . <br /> F. H 1'L 1)0; Vna, l_7A <br />