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_ `4 JOAQUIN LOCAL HEALTH DISTRICT <br /> OF OFFICE USE: 1601„x:. Hazelton Ave. , Stockton, Ca141. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued G <br /> (Complete In Triplicate) <br /> . )Plication is hereby made 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JB ADDRESS/LOCATION _2q 49 of N 1RRu e L.Lja CENSUS TRACT <br /> C net's Name =Ryinu(s ApgM3 Phone 362 — `1327 <br /> Address of C/4 1\4 T,112uCC4 n City f !_FLS+? c� <br /> C ntractor's Name ,7r = '_' V5' <br /> License #3j6.?7A Phone 304"17 <br /> I PE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-)P';;�UMP REPLACEMENT /7 <br /> Other <br /> L�STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER X <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Industrial Cable Tool Dia, of Well Excavation S <br /> Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> I MP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> I e REPLACEMENT: / / State Work Done p <br /> PUMP .REPAIR: /;;f-' state Work Done <br /> J +TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ft Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a.d 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 /> k LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iL.formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ?RIOR TO GROUTIN A FLN INSPE N. Son Joi.,qus €wrap Lo. <br /> STONED TITLE <br /> LORAW PLOT PLAN ON REVERSE SIDE <br /> � ) <br /> FOR DEPARTMENT USE ONLY Lodi, Colifarnia 95240 -aily <br /> PURSE I <br /> P1 PLICATION ACCEPTED BYej�����,�Q DATE ,v <br /> ITIONAL COMMENTS: <br /> PHASE II GROUT TNSPECTI9W PHASE III/FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY DATA i <br /> L 7a—K <br /> 6./77 9M <br />