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SAN JOAQUIN LOCALA1T DISTRICT . <br /> FOE OFFICE USE: 1601 E. Haze1"ton Al , Stockton, Calif. <br /> Telephone: (209) 466=6781 Permit No. 6 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .(Complete In Triplicate) t <br /> Application is hereby made to �the San Joaquin Local Health District for a permit to construe <br /> and/or install the work herein described. This application is;mce with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of, the ade in compliance <br /> the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /f tt/ CENSUS TRACT <br /> 11S=VV3-,14-43 <br /> Owner's Name Phone S <br /> , <br /> City <br /> Address ' � E <br /> k <br /> Contractor's Name _ License .��. p$1 Phone �ZZ-,& / <br /> TYPE OF WORK (Check) : NEW WELL /2/ DEEPEN -/ / RECONDITION / j DESTRUCTION /7 T <br /> PUMP INSTALLATION /, / PUMP REPAIR / PUMP REPLACEMENT <br /> Other +/ 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 16Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELI/42�— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS rW <br /> Industrial Cable Tool Dia. of Well Excavation �' �' � <br /> Domestic/private 1 Drilled Diad 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 G �- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor x <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> I - . Approximate Depth <br /> : <br /> DESTRUCTION OF WELLWell Diameter -- <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--t-o-`-or,-regulating weal-canstruction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 GROUT G AND A F -AL IN 5 P E CT ION. <br /> TITLE <br /> SIGNED / Ld <br /> AW PLOT PLAN ON REVERSE SIDE) <br /> DR <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 71 _ <br /> APPLICATION ACCEPTED BY <br /> . ,ADDITIONAL COMMENTS: <br /> PHASE II .GROUT INSPECTION PHA E III FINAL INSPE TION <br /> INSPECTION 8Y L(� � DATE /[- ,. <br /> INSPECTION BY BATE <br /> fa/77 2M <br /> T N IA9A Rev_ 1-74 <br />