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SlLv d'OAQ,.'.N LOCAL HEALT11 DISTRICT <br /> L'OS,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> LAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l Zj1aJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ -1 _7 <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and Qthe Rules and Re ulatio_n of the San Joaquin Local Health District. <br /> Yam ADDRESS/LOCATION / "' o �3 KUST` R <br /> LB CENSUS TRACT <br /> -per's Name <br /> y� Phone <br /> Sdress 33bo� /Cos ? e dz / d , city ?f!c `/ <br /> ntzactor's Name HQ IV IV :-.11- <br /> License # Phone <br /> L <br /> PE OF WORK (Check) : NEW WELL / %' DEEPEN /% RECONDITION /� <br /> �( DESTRUCTION /77 <br /> Im PUMP INSTALLATION / / PUMP REPAIR /_/-PUMP REPLACEMENT /—T <br /> Other /_/ — <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT.PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LI _E% PRIVATE DOMESTIC--WELL — PUBLIC DOMESTIC WELL _ <br /> INTENDED USE` i TYPE OF WELL CONSTRUCTION SPECIFZ IOW <br /> Industrial Cable Tool DiaJ; of Well Excavation „ <br /> _ Domestic/private Drilled Dia.'. of'Well Casing d <br /> � <br /> Domestic/public Driven Gauge of-,Casing ' <br /> Irrigation Gravel Pack Depth of,-Grout Seal <br /> _ Cathodic Protection Rotary Type!`of Grout <br /> _Disposal OtherOther -Wormation <br /> Geophysical: ' ? Surface Seal Installed By: <br /> -.S <br /> UMP INSTALLATION: Contractor -- + <br /> ` Type of Pump H.P. <br /> i k ' r <br /> UMP REPLACEMENT: /!/ State Work Done <br /> 1 _T <br /> �Q '.REPAIR: <br /> ' --- �_State._FlOzk .Done_.� •--"^^' �--.,�..�__-.,-.,,..�. .._... _ <br /> �x <br /> 4S.TRUCTION OF WELL: Well Diameter ;) Approximate Depth <br /> V <br /> Descrikgj11&tegria3 and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> �er completion of my work on a new well, I will furnisJi the San Joaquin Local Health District a <br /> ELL DRILLERS REPO ,of the well and notify them before ,,of the well in use. The above <br /> ormation u o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TO GRO AL INSPECTION. H <br /> IGNED :t TITLE <br /> P. OT P ON REVERSE SIDE ; <br /> RASE I USE ONLY j <br /> i 1 <br /> )'PLICATION ACCEPTED BY DAP' <br /> I)ITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> LE H 1426 uo„ <br />