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L <br /> SAN JOAQUIN LOCAL REALT14 DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATIONI' FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,26-# r' <br /> f <br /> ` THIS PERMIT EXPIRES l- YEAR FROM-DATE -ISSUED Date Issued b-10-7C <br /> (Complete In Triplicate) <br /> Application is b.ereby 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 � �a l C � �i t4CENSUS TRACT <br /> Owner's Name !y Ciy1 9� Phoneme <br /> � . lJ�-d b � City CC�'�tnkf-9 � �1 <br /> Address. <br /> Contractor's Name License # Phone VU Fl,; S <br /> TYPE OF WORK (Check) . NEW WELL / I DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> r PUMP INSTALLATION I I PUMP REPAIR 5�' PUMP REPLACEMENT /? <br /> Other /L% <br /> E <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 /> Industrial Cable Tool Dia.# of Well Excavation . <br /> Domestic/private Drilled Dia.iof Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type: of Grout <br /> I� Disposal Other Other Information.- <br /> 'Geophysical Surface Seal Installed B <br /> " <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I • <br /> PUMP REPLACEMENT: / / State Work Done <br /> L Y' <br /> PIM,REPAIR: .. State.-Work, Do V - <br /> DES-rRUCTION OF WELL: Well Diameter Approximate Depth <br /> »--� _ <br /> Describe Material and Procedure <br /> l <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 is true to the .best of my knowledge and belief. I WILL CALL FOR A GROUT INSPEC ON <br /> f PRIOR TO OUTING AND A FINAL INSPECTION. r <br /> SIGNED - PLAN 'ON DRAW�'PI, T` TITLE <br /> REVERSE SIDE <br /> 1 <br /> FOR DEPARTMENT' USE ONLY <br /> PHASE I <br /> APPLICATION ACCtFTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JAWINAL INSPECTION <br />" INSPECTION BYDATE INSPECTION BY DATE " <br /> -H 1426 ,Rev. I-74 _ . 3/76 2m <br />