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6.0 t124 lm SAN JOAQUIN LOCAL WEALTH DISTRICT <br /> FOR(OFFIC USE: 1601 E. Hazelton Ave, , r.Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> }� (Complete In Triplicate) <br /> A Application is hereby made ,to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work heein described. This application is made in compliance with San Joaqui3r <br /> County Ordinance No. ,1862 azd the Rules and Regulations of the San Joaquin Local Health District. <br /> t JOB ADDRESS/LOCATION 3dP.H, ^{ �B �� '� �� .I,C�:." /,¢d CENSUS TRACT <br /> Owner's NamePhone <br /> Address d / City © 's 1�" ✓.✓,fes <br /> Contractor's Name' ' License #/ 3 ,�Phone -Z <br /> t y <br /> TYPE OF WORK (Chec EW vELL-7--DEE RECONDITION /_7 DESTRUCTION f7 <br /> -- NST_Ai,LLATION �� REPAIR /_7 PUMP REPLACEMENT / V� <br /> Other / / O <br /> DISTANCE TO NEAREST: SEPT EWER 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 i 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 f/ <br /> Type of Pump H.P. /p <br /> PUMP 'REPLACEMENT: / / State Work Done <br /> State Work Done . <br /> 293 ,TRUCTION OF WELL: WelilDiameter 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 worl�,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 /> PRIOR TO GROUTING AND A FINAL INSZEELon. <br /> SIGNED TITLE ROY, <br /> t ( PLOT PLAN ON WERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7/ /,-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTIONP SE I FINAL INSPECTID <br /> INSPECTION BY rDATE INSPECTION BY DATE jq <br /> E H 1426 Rev. 1-74 1-74 2M <br />