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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> THIS PERMIT XP LS i <br /> (Complete In Triplicate) <br /> Application -is hereby made toithe San Joaquin Local Health District for a permit to construct } <br /> and/or install the work hereinl. described. This-application is made in compliance with San Joaquin {. <br /> County Ordinance No. ;the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION %d'�-7"1' rte. CENSUS TRACT <br /> Owner's Name LL l077— �4 Phone <br /> Address P_P_&jj301 LA-AJE City <br /> Contractor's Name (A,165CC>�6 })ATC W�66 0�G� � License �� Phone - % <br /> i < - - i <br /> TYPE OF WORK (Check) : NEW WELLDEEP N / RECONDITION- / / DESTRUCTION /_7 ` <br /> PUMP INSTKTION j PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> W IUB W <br /> DISTANCE TO NEAREST: SEPTIC TANK lob% SEWER LINES too 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 1CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation SD42_.` <br /> Domestic/private 3 Drilled �� Dia...,' of Well Casing <br /> Domestic/public Driven . Gauge of Casing /2 L , <br /> Irrigation ! Gravel Pack Depth of,iGrout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> if Disposal t Other Other Information 1 ; <br /> E <br /> Geophysical " - S_urfade Seal Installed By: <br /> CDS;! LWT <br />' PUMP INSTALLATION: Contractor W7 _ - <br /> TYpe of Pump -- '�' H.P. - <br />(PUMP REPLACEMENT / / State Work Done <br /> l <br /> PUMP .REPAIR:_. / / State Work Done <br /> DESTRUCTION OF.WELL: We11. Diameter � `. Approximate Depth 2r6 <br /> Describe Material and Procedure <br /> I hereby agree to-c'omply 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 /> 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR`TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1-71- TITLE ! L'01V'f 'W {`6y- <br /> } (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE S .� a <br /> ADDITIONAL COMMENTS: A <br /> PHASE II GROUT INSPECTION c PHASE III/FINAL INSPECTION <br /> INSPECTION BY C,6. , DATE S- z-�/' INSPECTION BY . '? DATE 17 <br /> 1177 _. . 2M <br />