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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. ; Stockton,-Calif.' - <br /> � I! Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> ' THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued <br /> u , (Complete In Triplicate) <br /> ,ppllcation is hereby made to the San''-Joaquin Local Health,Discrict for a permit to construct <br /> ind/or install the work herein described. This application is made. in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Pte,,.p xt z <br /> '[OB ADDRESS/LOCATION niiie AAFM-d C40%d Rd, e X44FRo����CENSUS TRACT_ ' <br /> )wner's Name JeP MAlrtchesce7TY _ _ Phone 4Q'2 6S/`y�3 <br /> 'address Ik@ l f1LP..vc ST" City STtc �FTya+/ . . <br /> c � <br /> :ontractor's Name OMI ✓f 2S nL Os- .R (r�-ne� 4&& License llA651�L Phone <br /> 'YPE OF WORK (Check): NEW WELL/7 DEEPEN /_% RECONDITION / / DESTRUCTION -'/- j <br /> t PUMP INSTALLATION / / PUMP REPAIRf/ /� PUMP REP110EMENT " <br /> Other <br /> I� <br /> )ISTANCE TO NEAREST: SEPTIC TANKrpt-4-, SEWER LINES /ff PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE'-PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE. ;-- 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS R <br /> Industrial '"� Cable Tool Dia. of 'Well Excavation <br /> Domesti:d/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> IN <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P. <br /> 'PUMP REPLACEMENT: / State Work Donees rVr`E7—Fl?oa: yoff0 <br /> 'PUMP REPAIR: /+ / State Work Done <br /> I F <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> II - <br /> ' 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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED eti.,_ TITLEda, <br /> x (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I f ` <br /> APPLICATION ACCEPTED BY !` <br /> VJJA, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION iPPHAAS,� III/ SINAL INSPECTION i <br /> ' INSPECTION BY II DATE INSPECTION BY /y _ DATES <br /> E H 1426 Rev. - I-74' <br /> °e 2M <br />