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SAN JOAQUIN LOCAL HEALTH DISTRICT ell / <br /> -TOT"OFFICE USE: 1601 E. Hazelton Ave. , Stockton,' Calif. /`4.s <br /> Telephone : (209) 466-6781 7 q <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7~ G _Z� <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued ,?-7 <br /> � 5 - -SIS (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`Ilv`j AJ <br /> (.rf4,V" Ulm ®SCSg C/�Lp"�tl CENSUS TRACT <br /> II. <br /> Owner's Name S Phone _ 83 7- 77/ 2, <br /> Address 1131 Ml 6S C4t-aiAj City- <br /> . <br /> Contractor's Name MARTI 4U Qj M License # Z,Sb�0 3 Phone °7.6- <br /> i <br /> a <br /> 'TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /7 DESTRUCTION /�"T <br /> PUMP INSTALLATION /T/ PUMP REPAIR / / PUMP REPLACEMENT I7 Q <br /> Other /_7 .. -� <br /> DISTANCE TO NEAREST: SEPTIC TANK 1W, SEWER LINES PIT PRIVY --- 1 <br /> SEWAGE DISPOSAL FIELD { Q(- CESSPOOL/SEEPAGE PIT -- OTHER — 1 <br /> PROPERTY LINE/qO. PRIVATE DOMESTIC WELL = PUBLIC DOMESTIC WELL �- h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _AL_ Drilled Dia. of Well Casing r ' <br /> Domestic/public Driven Gauge of Casing t� <br /> __ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _� Rotary Type of Grout v av- Uenf <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: CoN -vL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Ia. H.P. <br /> C <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP REPAIR:, / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4 :and the State of California pertaining to or regulating well"cons�r�uction. 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 GROUTI D A INSPECTION. <br /> SIGNED TITLE e)wAk,_r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY __�Lca , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTIONP 11 /FIN _ INSPECTION <br /> INSPECTION BY DATE /2 INSPECTION BY DATE Z- e <br /> ASO - 5_0 -�y„ZZ�, vd 7.7 <br />� T7T-17L,hA ao,. 7_7/. <br />