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r"11 ` 'N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 160_..x.. Hazelton Ave. , Stockton, Calms . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L s/64d <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7-_5a 6 <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 S W ��>e ,,, 0J t�.q �F iAdo tLd CENSUS TRACT <br /> As <br /> Owner's Name nXiu, X`-� -11" Phone � <br /> Address y6�0 u IA4: Ad City �trncil, d' <br /> Fd c <br /> Contractor's Name7 �?6ti 0ui� License 0 -11914 <br /> 6 Phone <br /> TYPE OF WORK (Check) : NEW WELL/) / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTAL ATION /% PUMP REPAIR/% PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES qd- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SS POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 4� <br /> X. Domestic/private Drilled Dia. of Well Casing /I,, enOli," ",., <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. 'r4 <br /> PUMP REPLACEMENT: / / State Work Done \ <br /> PUMP .REPAIR: /% State Work Done <br /> DESTRUCTION 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 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 <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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED `"` nn,oe` TITLE fSlr.mhc,, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �;f DATE <br /> ADDITIONAL COMMENTS: <br /> PHA.%g II A6UTjNSPECTION P III INAL INSPECTION <br /> INSPECT`�IJONf rAtTlE YNSPECTION BY DATE <br /> rZ / <br /> E H 1426 RA,._ 1_7A //a <br />