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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FC&,"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> A Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79 - 46 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, 7-� l <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 Joaquin4 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /,5:fZV . CENSUS TRACT 4 <br /> Owner's Name - ,moi 90 Phone <br /> Address Z.EV r City _ 60,01- <br /> Contractor's <br /> 0,01Contractor's Name SAN JOAQUI PUMPCOMPANY License #9" Phone3o_�Z' 7 <br /> TYPE 3OF WORK (Check) : NEW WELL .I I DEEPEN I I RECONDITION %%t DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT <br /> Other <br /> DISTANCE 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 t <br /> INTENDED USE TYPE OF WELL " " -CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 7}Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven '.Gauge of Casing <br /> Irrigation Gravel Pack 1. '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 /> PUMP REPLACEMENT: / / State Work Done 7 <br /> PUMF -REPAIR_:� / State Work Done ._lal ,ewV5 <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 /> 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 knowle ge and belief. I WILL CALL rFO�RpT�A�T GROUT INSPECTION <br /> PRIOR <br /> 0 GROUTI FINIAL INS TITLE . JA�y JtlUli� <br /> PUMP FUMY <br /> g&LrPLOT PLAN ON REVERSE SIDE) " <br /> FOR DEPARTMENT USE ONLY P Q BOX ZQ� <br /> PHASE I - L0dl, rnia <br /> t APPLICATION ACCEPTED BY C • 6 - DKi s <br /> ADDITIONAL COMMENTS: <br /> 11 v- <br /> PHASE II GROUT INSPECTION V PHASE III/FINAL INSPECTION <br /> 4 INSPECTION BY DATE INSPECTION BY ��_.� _ DATE- <br /> 2M <br /> F. H 1[126 RAu_ . 1-I li _ <br />