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_ S?m JOAQUIN LOCAL HEALTH DISTRICT <br /> _OF OFFICE USE: 160)S. Hazelton Ave. , Stockton, Calms <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. __5-,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-a3-�7 <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> aunty Ordinance No. 1862 and the Rul s and Regulations f the San Joaquin Local Health District. <br /> j 9YG s' �o� fec ��� <br /> )B ADDRESS/LOCATION �- �,�/ ��/?�U dF S. S%. 7,) h.v •� C�1%/Teti Leo�US TRACT <br /> mer's Name Qy 11 Ph/one 238--R133-7 <br /> 1dress a ( 66 4- L gi V et2 P& City 4c,�C,01,0 A-) <br /> )ntractor's Name _ -T.0, �C,L, �3�, S l License #c 2%Vo Phone <br /> :PE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ./ / <br /> :STANCE 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 <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> REPLACEMENT: State Work Done pS�fn�i� �c.✓ 7lif�-� / � �.�1�� c� L� <br /> 'JMP .REPAIR: / / State Work Done <br /> r• <br /> STRUCTION OF WELL: Well Diameter Approximate Depth a <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 /> 'ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTINQ AND A FIN4L I SPECTION. /> <br /> IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> `RASE I DATE <br /> .PPLICATION ACCEPTED BY <br /> .DDITIONAL COMMENTS <br /> PHASE IISPECTION PHASE.- II/FXNAL INSPECTION, <br /> _NSPECTION BY DATE INSPECTION <br /> i <br /> 1177 _ 2M <br /> F N IL9A Rav_ 1-7G <br />