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p/t ✓ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F006FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Mw Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL_., 1417 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION c --Cll CENSUS TRACT <br /> Owner's Name `/�, �qs'2 Phone <br /> Address + d j City <br /> Contractor's Name ,e "� License #/&ACPhone y ?474(v <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /-j . <br /> PUMP INSTALLATION /-7 PUMP REPAIR PUMP REPLACEMENT /7 <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 C� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation CJ <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 / ,4, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: State Work Done ` G ( r rf.4; �E' ai �/` <br /> PEES-TRUCTION 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 kr.ovle4e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN E . <br /> SIGNED TITLE <br /> RAW PLOT PLAN ERSE SIDE <br /> FORD ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II WA INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2�W <br />