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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 9/3 K <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 ap_7f <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of t�h�ef San Joaquin Local Health District. <br /> uB ADDRESS/LOCATION l0 ` 471? 9� �4 CENSUS TRACT <br /> net's Name A-rend ccl Phone <br /> Address ?2—no &&A71- City <br /> r <br /> ntractor's Name A - Al, Cl"reSS r,[JQC( 0,n License QZ&pfPhone 2K J,Jz <br /> PE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK 120i SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /SS-0(-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 X <br /> _ Domestic/private Drilled Dia. of Well Casing /�< <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S� <br /> Cathodic Protection _ Rotary Type of Grout C pir� <br /> —Disposal Other Other Information <br /> — Geophysical Surface Seal Installed By: A" ne Y,P <br /> fMP INSTALLATION: Contractor <br /> Type of Pump a H-P. <br /> '"'TMP REPLACEMENT: / / State Work Dones.._��_ <br /> MMP REPAIR: / / State Work Done <br /> I STRUCTION OF WELL: Well Diameter Approximate Depth 201 <br /> r Describe Material and Procedure �, <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> �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 /> --LL DRILLERS REPORT of the well and notify them before putting the-well in use. The above <br /> iformation is true to thebestof my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> �iIOR TO GROUTING A LINAL IN ECT <br /> CIGNED TITLE al <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR,DEPARTMENT USE ONLY <br /> PHASE I <br /> ?PLICATION ACCEPTED BY DATE a A <br /> iIDDITIONAL COMMENTS: e-ZX,usCl; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> L9SPECTION BY V DATE �6 17,9 INSPECTION BY DATE �jf�� <br /> .1177 "17i1 <br />