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F SAN JOAQUIN LOCAL HEALTH DISTRICT - '- <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4&-."`, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -,IS <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 /> GA ST r'"l A 10 %T. T3 v 1) TZ_ <br /> JOB ADDRESS/LOCATION CAST W -ra CENSUS TRACT <br /> Owner's Name S`tC}C-i�.'T n 1�AST LJ!!'Z�R. Y�1S�C R.►c.T Phone <br /> Addres8 ��+- `t S'r2£�7 City <br /> :'Contractor's Name s ACJ Co License # l2_ �V 8(,, Phone 11A L- Y- 7 3-6 1- <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/_7 RECONDITION DESTRUCTION:' <br /> PUMP INSTALLATION jE/ PUMP REPAIR 1_7PUMP REPLACEMENT f <br /> Other / <br />' .DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNE5 PIT PRIVY F` <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 f <br /> Industrial Cable .Tool Dia. of Well Excavation - `' <br /> _ Domestic/private ' 'DriA6d'- 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.. _�. <br /> Surface, Seal_Installed By-:. <br /> PUMP INSTALLATION: Contractor �: <br /> Type of Pump H.P. <br /> 'PUMP REPLACEMENT: S <br /> tate Warp Done <br /> PUMP 'REPAIR: 7 State °Work Done <br /> ES•TRUCTION OF WELL: Well Diameter 12`' W�Lis Approximate Depth L g LL + <br /> t� Describe MateICCAnl.3 <br /> al and Procedure F `To so 6 r- Su e SLE W <br /> SH w►� o L A C-MkJ EL. T SO ! u C CJ T C .S G OF ! La kl t&N1 S 14 CSX Ckb ` <br /> I hereby agree to comp) with all laws and regula ions of the San Joaquin Local Health District ' <br /> and the State of California pertaining to or regulatii:g well constiuction. 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 /> informatIGU7,In <br /> true to the.-best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOAND NAL INSPECTION. R1 <br /> SIGNED TITLE <br /> `• <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY . T ,E <br /> 11 <br /> APPLICATION ACCEPTED BY T� - _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f �p - ; NAL INSPECTION"'- ---- <br /> INSPECTION BY DATE R INSPECTION"BY DATE <br /> E H 1426 Rev.. 1-74 ,, - <br />