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SP^ JOAQUIN LOCAL HEALTH DISTRICT <br /> t)F uFFIC% USE: - 1601 ,,, Hazelton Ave. , Stockton, Calis,. 'If <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued—� <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San Joaqui? <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> LADDRESS/LOCATION 15265'p -9r1r1c�foeq��(y CENSUS TRACT <br /> gessr's Name y S I 6Phone � fJG - i 0 r% S.5 ri St</ zV� 1Cp// City -7t7�7"1 e C Cry <br /> tractor's Name l�n �� ,1 s:, C a_T%�X License II 2 Phone <br /> y- �� �2�s135-„ <br /> E OF WORK (Check) : NEW WELL /(J DEEPEN/_/ RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> TANCE TO NEAREST: ,,SEPTIC TANK/+J'dft-SEWER LINES /go PIT PRIVY <br /> SEWAGE DISPO_SA,,��LnnrELD � CESSPOOL/SEEPAGE PIT � OTHER l(� <br /> ��s PROPERTY LINEfW PRIVATE DOMESTIC WELL/f� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation i7 v <br /> ./ Domestic/private Drilled Dia. of Well Casing 3�. w <br /> �1e�) <br /> Domestic <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ men k,. 1 <br /> L Disposal Other Other Information <br /> -- Geophysical Surface Seal Installed By: <br /> P INSTALLATION: Contractor <br /> Type of Pump H.P. j <br /> ^'P REPLACEMENT: v` <br /> / / State Work Done <br /> .REPAIR: <br /> / / State Work Done <br /> LTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 7 ereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> _ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> kL DRILLERS REPORT of the well and notify them before putting the. well in use. The above <br /> ormation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ��77R TO GROUTING AND A FINAL INSPECTION. <br /> �NED ,7_/;n old'e6e/a TITLE :;i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR TMENT USE ONLY PLATE 11, Page 5 of 16 <br /> ,ASE I <br /> LICATION ACCEPTED BY � _ I' DATE <br /> APITIONAL COMMENTS: ---1 / <br /> PHAS II GR WT INSPECTION PHASE I/FIN INSPECT ON <br /> PECTION BY / tr DATE INSPECTION BY V � DATE <br /> u �i.�� .,___l �Gl� 1,.rP�f • 1 /77 . ->M T' <br />