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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. JF-�-�6 (•;' <br /> 7f-7Y1P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued tl-J�-7L <br /> Application is hereby ride ( eTriplicate) <br /> 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 Heath District. <br /> JOB ADD"ESS/LOCATION <br /> Owner's Name e Phone <br /> Address Rd <br /> city <br /> Contractor's Name` <br /> License /ty5��hone <br /> — <br /> TYPE 0: WORK (Check): NEI. WELL /Z7--I)-EEPF.N /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /Zk=-rutV REPAIR /-7—PUMP REPLACEMENT /7 �- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t- 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 �, gable Tool Dia. of Well Excavation <br /> __�meatic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing /.I <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodle Pra etioft Rutnry Type of Grout 9 S <br /> �fe�dp l. — /.- i . , Other Other Information <br /> Geophysical Surface Seal Installed Bye <br /> l <br /> PUMP INSTALLAi ION: Contractorto <br /> Type of Pump <br /> PUMP REPL.,,,ElO:NT: /% State Work Done <br /> PUMP REPAIR: /7 State Work Done , <br /> L'ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materinl and Procedure <br /> I hereby agree t.: comply with all laws and rngulatlons 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 • <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 INSPECTION <br /> 'RIOR TO CRO TI ANU A FI INSPECTION_. <br /> SIGNED <t TITLE �Liis�t.1-jam <br /> T—RAW PLOT PLAN ON REVERSF. SIDE <br /> VGR bY.PARMUT URL OULY <br /> vvv1A(!ATI0N ACCY.PIP.D BY _ _/ fti ,. DATE <br /> 0DITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION 2HASE III FINAL INSPECTION <br /> INSPECTION By h./- - - DATE INSPF.CTIC" -v _ IDATE . _ <br /> F H 1426 Rev. 1-74 L/75 2M <br />