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Q-kvw <br /> r -'►'- -- i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , . Stockton, Calif. T p1 <br /> Telephone : . (209) 4661-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ( (Complete In Triplicate) ! <br /> Application is here0y 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 nd ,the Rules and Regulations of the Sa_n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( 12-6 CENSUS TRACT <br /> Owner's Name �ff�.,lC /-� l��✓ ��7� "�, 55�. � �_2 7 t <br /> / Phone <br /> Address V�� city 4 E <br /> Contractor's Name <br /> License # Phone <br /> a <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION .` PUMPOREPAIR / / PUMP REPLACEMENT <br /> Other / / -- <br /> . r <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 /> Industriald Cable Tool Dia. of Well Excavation N <br /> Domestic/private f Drilled Dia. of Well Casing , <br /> Domestic/public 1.1 Driven Gauge of Casing <br /> irrigation ti Gravel Pack Depth of Grout Seal <br /> Cathodic Prote fiion 1 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 <br /> PUMP :REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well. D ameter 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 /> j 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!,,461'1"-VT`n tify them before putting the well in use.. The above <br /> informatio is true to ttie best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTIN AN FINAL INSPECTION. <br /> SIGNED ' " TITLE <br /> s (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I' <br /> APPLICATION ACCEPTED BY (A�. DATE f - - <br /> ADDITIONAL COMMENTS: ' <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION / 0 <br /> INSPECTION BY DATE jF}` INSPECTION. r' TE f�, �o <br /> 6/77 2M Z, <br /> E H 1426 Rev. , 1--74 <br /> .._ <br />