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C ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7/ 4 �b <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0-//- <br /> (Complete <br /> o-i/(Complete In Triplicate) pp p .--t ',?- <br /> Application <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 Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> 2T7S-l-'i�1r:_`E( ct,o7Trp%l <br /> JOB ADDRESS/LOCATION Li 'b £Rte, /P.L c1 r to- � RliO jTCENSUS TRACT <br /> wn <br /> Oer's Name Zoe Z: Phone <br /> Address _� -2 �C4_/'/ C,° ��d' City <br /> Contractor's Name ne A-- J�� k+ _ License A/41313 Phone <br /> Lobi <br /> - TYPE OF WORK"(Check):` NEW WELL-1-7 DEEPEN/7 RECONDITION-/7 "'DESTRUCTION-f7- <br /> PUMP <br /> ESTRUCTION'"% -PUMP INSTALLATION / J PUMP REPAIR )5;� PUMP REPLACEMENT /7 <br /> Other / 7 <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 /> Domestic/public Driven Gauge of, Casing <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor ✓?.�� <br /> Type of Pump 7 a C ZLi C, H.P. �, L) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: ^V State Work Done +`iLL 1� v �, cj2p t (Z ,� <br /> JpESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 DAY! <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Districl <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is t ue to the best of my knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AND A FIN SPECTION. <br /> SIGNED TITLE <br /> a-IRRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/11 �7�1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OqUT/ INgPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />