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'V it <br /> S� J�}AQ.�C IN I.0CAL HE�H 1D14IRICT� a j <br /> FORIOFFICE °USE: 1G01il. kazelton Ave. . Stockton, Calif.• <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6_ VLP4F <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-,,IS-26 <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 .2q3 a `/ • VL , CENSUS TRACT <br /> .Owner's Name <br /> 1GPhone <br /> Address city CSC'dL_0n./ <br /> ij <br /> Contractor's-Name ;� j,,.� License #62 c 0 Phone LAW,7 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /? RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /_7 PUMP REPLACEMENT ./� <br /> k Other /7 <br /> 1 <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> K <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USEr TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/pr-i- ate- ___Drilled - : - -- Dia;---of -Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> Ta <br /> PUMP REPLACEMENT: State Work Done V el y� r <br /> .. .-State 'Woik-Done <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 fura3sh 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 -beilef. I' WILL""CALL FOR A GROUT: INSPECTION <br /> PRIOR TO G -TING MIR _A FINAL. INSPECTION. x. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> — .FOR DEPARTMENT USE ONLY - -- _ <br /> PHASE I <br /> YF1 i s y� <br /> APPLICATION `ACCEPTEb BY DATE 7�G <br /> ADDITIONAL COMMENTS ' t ' —Z <br /> 1411­"�,, PHASE'"II 0VT "INSPECTION PRASE II FINAL INSPECTION <br /> INSPECTION BY DATE }S INSPECTION BY DATE <br /> 'E H 1k ,:.` Rev. 1-74fT�'� t ' 1-71L 2iwf <br />