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,4N JOAQUIN LOCAL HEALTH DISTRIC- <br /> FOS OFFICE USE: 16e.. E. Hazelton Ave. , Stockton, C, ,,.f. <br /> ,S Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nov�_2/V 9�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(;7-161-2 <br /> (Complete In Triplicate) !�T <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /S/.�P �fe CENSUS TRACT <br /> Owner's Name \ 7 Phone SSP- .:25;06_ <br /> Address /V -1 F 4 s����� � / Cit G <br /> Contractor's Name % - 6r , License #.7%r Phone <br /> ;71r.Kky AAAA-AS011IcH <br /> TYPE OF WORK (Check) : NEW WELL _� DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK t ZSr SEWER LINES I L s PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT _4L. 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 2 <br /> Domestic/private Drilled Dia. of Well Casing (� " <br /> Domestic/public Driven Gauge of Casing 160 !s-1 - G <br /> Irrigation _ Gravel Pack Depth of Grout Seal S"o Fr" <br /> Cathodic Protection _ Rotary Type of Grout ~7— <br /> Disposal Other Other Information of <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -2_ <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 df 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 owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE ON. <br /> SIGNED =tf&&mfTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DAA <br /> ADDITIONAL COMMMtS: ® n 14 1 /1" <br /> SC9'Grl <br /> PHASE OUT INSPECTION PHASE f107FINAL SPLCTION <br /> INSPECTION BY D __-- +NSPi? <br /> 77 <br /> U A s <br />