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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: VVV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZF-l��1 <br /> THIS PERMIT EXPIRES I 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 6S'" O - q�see a CENSUS TRACT/� <br /> Owner's Name �f Phone d v239kS-O <br /> Address o City / "I I Y e--e <br /> Contractor's Name �6/4 d License #3-QJc-1CaPhone <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN / / RECONDITION / / DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES c5_Z) 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 r <br /> e 'Domestic/private l.�—Drill.ed Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection z--Rotary Type of Grout O <br /> Disposal Other Other Information �y <br /> Geophysical Surface Seal Installed By: w-r--� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all haws and regulations of the San Joaquin Local Health District <br /> and the State of California_ pertaini.ng to or regulating well 'constructi.on. 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 GR UTING AND 4 FINAL INSPECTION. <br /> SIGNED a TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPWTION PHASEAII,/FINAI, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE jr <br /> �g G�Ti�+ i+u- rte GrJ� <br /> E H 1426 Rev. - 1-74-74 n�77""?/2M <br />