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- r <br /> � S.AN JOAQUIN LOCAL AL'43TRICT <br /> FO& OFFICE U E: / 1601 E. Hazelton Ave. , St&kton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. LG/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6- <br /> (Complete In Triplicate) <br /> Application s tereby 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. ,18/62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f VQ / 4K.Z%I�CENSUS TRACT <br /> Owner's Name /��,(� i�T �. Xi� Phone <br /> Address City <br /> Contractor's Name , �NNi`MQS �l aS �L ',� �d r� License #,?q 1.3 Phone 6.2.:2 1 <br /> TYPE OF WORK (Check) : NEW WELL V�(/ DEEPEN /% RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT 17 <br /> Other L_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW.M LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Q 10CESSPOOL/SEEPAGE PIT 'OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WALL '' 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 RN <br /> Domestic � - - <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ,S/a b b ajwe � <br /> Geophysical Surface Seal Installed BY: W.`jLet' <br /> PUMP INSTALLATION: Contractor A,4yZ- G4 <br /> Type of Pump H.P. z <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /% State Work Done <br />,DES•TRUCT.ION 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 J <br /> z_true to h e f y-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U AND CTION. / �O <br /> SIGNED 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 /> P II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE r�, INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 2M <br />