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FORSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made to the San (CompleteJ aquin Triplicate) <br /> 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 <br /> 4739 Q*N1Baj) j <br /> CENSUS TRACT <br /> Owner's Name r7j r i S <br /> Phone <br /> Address )BA L <br /> --qAq. � City <br /> Contractor's Name kit �Ll. o ,P License # �Od� <br /> 6— Phone -S <br /> TYPE OF WORK (Check) ; NEW WELL/ DEEPEN RECONDITION <br /> PUMP INSTATION � �/ DESTRUCTION /? , <br /> / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISFANCE ''.CO'NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD f PIT PRIVY <br /> _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY <br /> INTENDED USE TYPLINE - PRIVATE DOMESTIC WELT, --- PUBLIC DOMESTIC WELL. -' <br /> E OF WELL <br /> ndustr� CONSTRUCTION SPECIFICATIONS <br /> Cable Tal Dia. of Well Excavation ()�/ <br /> . Domestic/private Drilled Dia, of Well Easing <br />�^ Domestic <br /> /public Driven Gauge of Casing <br /> T <br /> IrrigationDriven <br /> Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> i Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP °REPAIR: / / State •Work Done . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stateiof 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 INSPECTION <br />'RIOR TO GROUTTNG AND A FTN INS EION. <br /> iIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE 'ONLY <br /> dPPLICATION ACCEPTED BY <br /> JDDITIONAL COMMENTS: DATE <br /> w <br /> PHASE II GROUT INSEF.ET P E II NAL INS ECTIO <br /> INSPECTION BY / DATE INSPECTION�BY <br /> DATE <br /> 411-1 <br /> E H 1426 .Rev. 1-74 1177 _ 2M `30 <br />