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�z <br /> V1601 <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;V-4s"4 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION !!? <br /> CENSUS TRACT <br /> Owner's Nam /� 11L4 Phone ?.3/ / O..--> G <br /> l � <br /> Address ! :. City, �� <21e �IV <br /> Contractor's Name FG /�U ._.. License #42L-3:7-sone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 'RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 1—/ PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other / � !' J L-L - '�- /Z.) fv <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 4 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 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> -.PUMP .REPAIR: J" State Work-Donees <br /> ZES-TRUCT_ION OF WELL: Well Diameter € 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 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 G UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE � 24- G41,I -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY (1 � - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA,%%ITI0ffININSPECTIO)( <br /> INSPECTION BY- DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />