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Page 36 of 51 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POE OFFICE GSE: 1601 E. Hazeltod Avd; Stockton. Calif. P' <br /> w Telephone: (209) 456-6781 <br /> APPLICATION FOR WELI CONSTRUCTION OR PUMP PERMIT Peralt No.7Ltd <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Data Issued - / <br /> (Complete In Triplicate) <br /> ..pplttati0a £s 6ereb mode to the San Joaquin Local Health District for a pereit to construct <br /> andlor install the work herein described. This application is msdo in compliance with San Joaquin <br /> -County Ordi"AcC No. 1862 and the Rules and Regulations of the San Joaquin.Local HeAxch District. <br /> a33!fb racc,ag c 9d <br /> f�.r.rn . <br /> 'ADB ADDRESS/LOCATION Ne2r4hof 0 n N . -e-hat rrn(VrrctSs TRWI .1 <br /> DuneY'$ NameIt f <br /> ,ddreas •FIZ& SRI City �� <br /> Contractor's Name WPnne Ips l�Fn' �jrllOr l,J� Znc License p jQ$13 Phone <br /> TPE OF WORK (Check): NEW WELL ST DEEPEN /� RRCONDITION /'7 DES4RDCTIDN 17 <br /> PUMP INSTALLATION LI Pule REPAIR L-7 PUME REPLAC&F[ENT I <br /> Other f-1 - <br /> rISTANCB TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAI, FFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DDID;STIC WELL — PUBLIC DOMESTIC- LL�— t <br /> IHTaNFlED USE TYPE OP WELL CONSTRUCT ION SPEGIPICATSDNg j N <br /> Industrial Ceble Tool Ola. of Well Bxe avatien r1" Q <br /> Domeselc/private Drilled Din. of Well Casing W <br /> Domesticlpublic Driven Gauge of Casing 'h gi N` <br /> Irrigation Gravel Pack Depth of Grout Seal 10' <br /> CathwJic Protection Rotary Type of Grout Bp���.(,f�l 'FLP,+ <br /> ,Disposal �^ Qeher _ _ Other InformCitce fpt3 'r _ <br /> Ge6phya;cal Surface Seal Eoscalled ay: <br /> PUMP INSTALLATION: Contractor Kk l'JQ <br /> Type of Pomp <br /> Al I Po.CnI L.rC.� <br /> 'UNP REPLACEMENT: LI 'State Work Done r + <br /> PUMP REPAIR: State Work Done <br /> )ESIRUCTION OF WELL: Well Diameter Approximate Depth V^6t - <br /> Describe Material and Procedure <br /> ' I hcrcby agree to comply vicle all Laws and reguLtatlona of the Gari Joaquin Local Health Diaeriet <br /> --and the State of California pertalotng to or regulating wellconstruction. Within FIFTEER RATS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> HELL DRILLERS REPORT of the ytli and notify them before putting the wall to use. Tho above <br /> , information is true to the b"t of- my knowledge and belief. I WILL =L PDR A GROUT INSPECTION <br /> PRIOR TOC ?TING AND A FINAL INSPECCION. TITLE 7J'� <br /> ETCHED J_:4T_1' l.J' Do pt0-� PLAN DN REVERSE 51D6 _ <br /> POR DEPARTNBNT DSE ONLY p <br /> PHASE I TE <br /> .APPLIGITION ACCEYYED BY DA <br /> � _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT'INSYECTEON PHASE ��l!PINAL.INSPECTION <br /> I[�SPEC`PIION 8Y DATE INSPECTLON BY�7LiSh�H' ATE <br /> 9/2011 <br />