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SAN JOAQUIN LOCAL, REALTH DISTRICT l <br /> FOR.OFFICE USE: 1601 E. Hazelton< ►v a. , Stockton, Calif. <br /> Telephoner; (209) 466-6781 <br /> APPLICATION FOR WE'LL CONSTRUCTION OR PUMP PERMIT Permit No.—/ <br /> .. - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , !/ <br /> _tea„ (Complete In Triplicate) <br /> Application is Hereby made to-trie San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein describb d. _ This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a the res and Regu tions ofLJh an Joaquin Local Health District. <br /> JOB ADDRESSILOCATION �c C�`�-, c,_ . _� `�CENSUS TRACT <br /> Owner's Name w Phone 2 3�_� <br /> Address o q %.c,,ne oma- ocA--st�. City <br /> Contractor's Name License �� Phone <br /> ccr�,,�,�e 1�r`zz/yc gid. 32/ <br /> TYPE OF WORK (Check) : NEW WELL /><[ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK !U 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <<� CESSPOOL/SEEPAGE PIT OTHER �j <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 1 <br /> Domestic/private Drilled Dia, of Well Casing G " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation A/ Gravel Pack Depth of Grout Seal ?W /7-: <br /> Cathodic Protection �/' Rotary Type of Grout ZE-d WNl7-2_`- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <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 laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAIS <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 tru to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROVTIO6 D A FINAL INSPECTION. <br /> SIGNED / TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> Iolloe FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OROM/INSIFECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY �' DATE INSPECTION BY DATE / <br /> /D/'`7?7 41t t- �o�Ay 4l An U o.- �-Ce 3" h, ��Q� G 1 f 77 2M <br /> E H 1426 Rev. 1-74 ""C7 ` <br />