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JT SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi O ICE US • 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZG-j136 P <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'Y�alth 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 & b1p <br /> ��^' - ,s� � � i n t3 , CENSUS TRACT <br /> Owner's Name it,lk" -S, , Phone <br /> Address S` y Ci <br /> tq � <br /> Contractor's Name ;°� J License # /f,3 7)- Phone y <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/7 PUMP REPAIR /ZC� PUMP REPLACEMENT- 17 <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 <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 /> �C 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: ContractorG-*> <br /> Type of Pump H.P. 3 n <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP 'REPAIR: <br /> State Work Done" <br /> as <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 _ . kn le4ge-4belief. I WILL CALL FOR A GROUT INSPECTI <br /> QX <br /> PRIOR TO G OUTIN ANDA FIN IN E 0 <br /> SIGNEDa�-:;, o w � TITLE <br /> RAW PLOT PLAN ON R MRSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION an INSPECTION <br /> INSPECTION BY DATE INSPECTION 444 A <br /> DATE <br /> E H 1426 Rev. 1-74 h/75 2m <br />