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` JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS: OFFICE USE: 160_,—,�. Hazelton Ave. , Stockton, Cali-r. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/7-7E <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 Joaquin <br /> County Ordinance •No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> QC 4j E�ilJ V o c(viz d 1.-e Hh,,rr c­ &,-,; <br /> JOB ADDRESS/LOCATION �¢�, l4s�i` -� Lc� Icf-h/t��tCENSUS TRACT <br /> Owner's Name ,� t{ i 5 �Cc,�?� ( r R✓Za ,� <br /> Phone _3_C�-- /(;C)V _ <br /> Address / S` 20S ti %� ^i N�GC� i' _._-- -- City <br /> Contractor's Name _?Sari Joaquin Purrp ate. _ License # 316 32ffPhone,?6 <br /> v s!anof 539 jocgUP ' p ur <br /> TYPE OF WORK (Check) : NEW W&:'� f..� � EPS T� /% RECONDITION DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR. ?P PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER "1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 0 <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: State State Work Done <br /> PUMP .REPAIR: /�State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> v <br /> Describe Material and Procedure <br /> L 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 a <br /> +TELL 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 /> 'RIOR TO G TING AND A FINAL INS CTION. <br /> ;IGNED - `�� � �_— TITLE �'en eoa�9n �'uwp U. <br /> 'Ca <br /> (DRAW PLOT PLAN ON REVERSE SIDE) « ' IR6 f 5-•r-le�=-iF �ri�h� <br /> FOR DEPARTMENT USE ONLYol , Com <br /> 'RASE I ,fj.rr€a 9524c) <br /> - <br /> �PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE,JI GROUT INSPEC ON PHASE III/FINAL INSPEC ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> H 1426 RPlr- 1_74 ' ^r ^•• <br />