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SAN JOAQUIN LOCAL'REALTH biSTRICT <br /> 1G'OArOFFICE USE: 1601 E. Hazelton Ave;, `Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J,11_ az20 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4,Z j, <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. 1a1' CENSUS TRACT <br /> Owner's Name k 1 VL i <br /> Phone ,I _AjA. j <br /> Address,--. Z'sg�- - .. .. � ._. City A!!�SC 1� <br /> i <br /> Contractor's Name ; o License # p Phone -7 <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN '/ 7RECONDITION /_7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR _0 PUMP REPLACEMENT /j <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> _ SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ''• '� -� 4 7 " ,PROPERTY .LINE =PRIVATE DOMESTIC WELL - PUBLIC/DOMESTIC WELL („ <br /> INTENDED USE , .�* _TYPE OF WELL CONSTRUCTION,SPECIFICATIONS V <br /> Industrial.- Cable T601 Dia. of Well Excavation <br /> Domestic/private •��. k '-,Drilled' L Dia. of Well Casing "40 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel' Pack Depth of'Graut Seal <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal Other Other Information, .,t <br /> Geophysical _ Surface Seal Installea BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / '/ State Work Done ' �^ <br />-'PUMP- REPAIR:• ''State Work Donee= j') ,.,, <br /> ES;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-61the well slid notify them before putting. the well in use.. The above <br /> information is trae to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG ANDA FVINAL INSPECTION. <br /> SIGNED TITLE <br /> ;S {'A (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL;,COMMENTS,:z <br /> 1 'PHASE;.11 -G UT INSPECTION P II N INSPECTIQN <br /> INSPECTION BY A4,1 DATE INSPECTION BY DATE 1,4 <br /> 't E H 1426 Rev. 1-74 1-74 2M <br /> -' r, <br />