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SAN JOAQUIN .LOCAL HEALTH DISTRICT - ILA <br /> FOF, OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 77-�3�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> -7D THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�o <br /> ' (Complete In Triplicate) <br /> 1pplication is erelr made t- the San Joaquin Local Health Di4trict for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Jaaquf <br /> ,ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 10B ADDRESS/LOCATION �� h'� y�� �� CENSUS TRACT <br /> haner's Name �,it � ���,4 Phone r <br /> address / ��:� "E /��✓t2city fScr4, <br /> ,ontractor's Name License , ?3114/ Phone - J <br /> 'YPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTAL TION / '/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other '/ / <br /> )ISTANCE TO NEAREST: SEPTIC TANK�_# SEWER LINES -----PIT PRIVY <br /> SEWAGE `DISPOS�h FIELD CESSPOOL/SEEPAGE PIT _ OTHER ---� <br /> PROPERTY LINAWRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ti TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � f y Cable Tool Dia, of Well Excavation <br /> Domestic/private p Drilled Dia, of Well Casing y <br /> Domestic/publics, Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of- Grout Seal UV <br /> Cathodic Protection __ - Rotary_ <br /> Disposal � ` A- . ' Other Other Information <br /> Geophysical- - _ _Surface Seal Installed By: �t,S ,.,,•in �( <br /> 'UMP"INSTALLATION: Contractor 04-J ✓� /t / <br /> Type of Pump if H.P. <br /> 'UMP REPLACEMENT: / / State"-Work Done <br /> 'UMP <br /> REPAIR: <br /> _ _ /j State Work Done- <br /> 1ES•TRUCTION bk. WELL: Well Diameter 'r Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws--and-regulations of the San Joaquin Local Health bistrict <br /> tnd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> ifter completion of my work WI-Wfl, I ill furnish the San Joaquin Local Health District <br /> JELL DRILLERS REPORT of thethem before putting the -well in..use. The above <br /> nformati true the bo edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR R �A Fh;A>IGNED �' i TITLE <br /> .PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I . <br /> OPLICATION ACCEPTED BY CrCn—� DATE O <br /> A �2 <br /> ADDITIONAL COMMENTS: • y ' <br /> PHASE^II"GROUT"INSPECTION ;' :Pi. , S FIN ---INSPECTI N <br /> [NSPECTION"BY__- _,_. . DATE ''~ "_`INSPECT.1 BY4 DATE_ , 7� " v <br /> V <br /> f77 2M <br />