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I JOAQUIN LOCAL HEALTH DISTRIC <br /> FOR OFFICE USE: V 160rE. 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 - O-7� <br /> (Complete In Triplicate) <br /> Application 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 /> JOB ADDRESS/LOCATION 119�176 //), 111VW CENSUS TRACT <br /> Owner's Name R Liz LZzgFiTi/d Phone G3_�;- S 3 91 <br /> Address 27766 (lOR2R- / h}oJ)jA,( <br /> - C 12_h City Rn_c��_ <br /> Contractor's Name �}/��� a� License 4 Phone <br /> c <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_7 RECONDITION /_7 cDESTRUCTION E7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP'RSPLAT;F <br /> Other <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing 6 <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. JQ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done r <br /> n � <br /> DES"TRUCTION OF WELL: Well Diameter _'gx Q Approximate Depth / L <br /> Describe Materia and Procedure „�� s Baffin <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 /> ?RIOR TO GR U I G D A F NAL INSPECTION. <br /> SIGNE TITLE <br /> l (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY o �� f� DATE -7—,27-7,6' <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE III UINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ( DATE -�� <br />