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i <br /> ag SAN JOAQUIN LO('A.,-PIAUTH DISTRICT <br /> TOEOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -alp <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 wade in compliance with San Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f JOB ADDRESS/LOCATION 75S,2 hl - CENSUS TRACT <br /> Owner's NamePhone 6�1Q <br /> Address 7 k2 City <br /> Contractor's Name License <br /> 3 Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /� PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S_C)• PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 7` PROPERTY LINE - PRIVATE MESTIC WELL -_MPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Caging <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other - Other Information 6' — ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /? State Work Done <br /> ES•TRUCTIQN OF WELL: Well Diameter Approximate Depot <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 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 A2 FINAL SPECTION. <br /> SIGNED TITLE <br /> 41 4z z:u <br /> (Rpw PLO PLAN ON REVFNSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE z -� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY&jn2AwDATE INSPECTION BY DATE <br /> r <br /> } E H 1426 Rev. 1-74 1-74 2M <br />