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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 y-,24/ <br /> I (Complete In Triplicate) <br /> I Application is Ai ebylmade 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. 1 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i JOB ADDRESS/LOCATION/ 1'n1 S. Qs Iahonk ; A mi W, ni nCknNE CENSUS TRACT <br /> e Owner's Name--r0NY SIUVWi SONS -1)A-1RjY Phone <br /> Address _23R(Qn ki. ;r4cY-TDNG go City AcArnpo �.. <br /> Contractor's Name (�;OP4R1N(., -P(1(y)(p _ License_ #7j)9A 3f Phone-7Z <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /% RECONDITION f7 i DESTRUCTION /7 <br /> 111 PUMP `INSTALLATION /1;?�PUMP REPAIR /—/—PUMP 'REPLACEMENT <br /> 1 Other / / al <br /> DISTANCE TO NEAREST: SEPTIC TANK ;,'SEWER EINES^; PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD - C S'SPOOL-/SEEPAGE 'M OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL— .Z <br /> INTENDED USE }TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; CableiTool Dia. of Well Excavation ; C <br /> Domestic/private Drilled \;• Dia. of Well Casing <br /> Domestic/public J Driven Gauge of Casing _ <br /> -Irrigation " Gravel Pack`,----Depth of-arout-�Seal <br /> Cathodic ProtectionRotary Type of Grout ' ? <br /> • Disposal �• Other Other Informattbn <br /> Geophysical Surface Seal Installed BY: C <br /> PUMP INSTALLATION: Contractor <br /> MV <br /> 2 <br /> Type of Pump 131S OLAM I LISE-0 Cl']l:; ui neLa H.P. . . n <br /> --W <br /> PUMP REPLACEMENT: /. / ;jState Work Done <br /> i <br /> PUMP .REPAIR: /% State Work Done s <br /> ' DES•TRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws -and-regulations of'the San Joaquin Local Health bistrict <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 ue to the best of my knowledge and belief. I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR TO G G ARD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> k•!/ .- (DRAW PLOT PLAN ON REVERSE SID <br /> OR DEPART T USE ONLY <br /> `'PHASE I <br /> 'APPLICATION ACCEPTED BY DATE <br /> k4DDITIONAL"'COMMENTS: <br /> 'PHASE, II,GROUT� NESE ASE II/FINAL INSPECTION <br /> \SPECTION BY 1:1 'i DATE INSPECTION BY DATE <br /> 1/l7: - ' 2M <br /> ' H1426 Rau. 1-74 <br />