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SAN JOAQUIN LOCAL HEALTH DISTRICT �J <br /> OFFICE USE: 1601ww. Hazelton Ave. , Stockton, Cal�r %/" <br /> Telephone : (209) 4:56-6781 f/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ Date Issued ---2`4 -7d <br /> (Complete In Triplicate) <br /> )lication is hereby made to the San .Joaquin Local Health District for a permit to construct <br /> Irl/or install the work herein described. This application is made in compliance with San Joaquin <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 01 <br /> �3 ADDRESS/LOCATION 1Mrr16UA f- S'OILk Q Q 1 CENSUS TRACT <br /> -ierIs Name E T 1 r(.lCk-1no _ -- Phone !M/-319 <br /> 'dress l 99 _ City <br /> =tractor's Name License # p ;Phone 5 <br /> 'E OF WORK (Check) : NEW WELL /i / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> iTANCE TO NEAREST: SEPTIC TANK :3(pi SEWER LINES PIT PRIVY IJI- , - - <br /> SEWAGE DISPOSAL FIELD dCC�t CESSPOOL/SiEEPACE PIT AfX OTHER 61 <br /> PROPERTY LINE/a PRIVATE DOMESTIC WELL —,-- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ExcavationDili <br /> Domestic/private -_� Drilled Dia. of Well Casing —� <br /> Domestic/public Driven Gauge of Casing 1 <br /> - Irrigation Gravel Pack Depth of Grout Seal % <( <br /> Cathodic Protection �_ Rotary Type of Grout 6 _rx +nnj+e- <br /> _Disposal Other Other Information iianLOtlD'1` <br /> Geophysical Surface Seal Installed By: _ <br /> `,T INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r. - <br /> TMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> >-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> !JIC( Gv eLLs �-n ctJ7' ,7e �-fCs�,i�c 5 P��,��.��Caz ��Yru./• �'G�/ /, � �� c� �<_kyL•//da-,J <br /> zereby agree to comply with an laws andegulations of the San Joaquin Lo al Health District <br /> _J the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> P"LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> TIOR TO GROUTING. AND A FINAL INSPECTION. <br /> IGNED TITLE �[ <br /> _ (DUW P OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PLICATION AGL4PTED ,BY DATE <br /> ..DITIONAL COMMENTS: f d <br /> PHASE II GROUT INSP�OTION PHASE III F .N L I96PECTION <br /> SPECTION BY DATE , INSPECTION BY DATE <br />