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SAN JOAQUIN LOCAL ]ii.hr 714 D1,;Trt' <br /> 7F_Fn• OFFICE I7SE: 1601 E. Hazelton Ave. Stockton, :nlf f . <br /> Telephone: (209) 466-67S] <br /> APPLICATION FOR WELL CONSTRUCTION OR P1 W. PF,RffIT Permit No. <br /> THIS PERMIT EXPIRES : Y';AR _FROM DATE; ISSt1F._n Date Issued <br /> (Gnronlete In :riplicrnto) <br /> NP','1lcation in hereby made to the San Jonquin Locnl 11enlc11 919 trlct for n permit to construct <br /> and/or install the work herein described. This application Is :jade in compliance with San Joeymis <br />:ounty Ordinance No. 1862 and the Rules and Regulations of the Say Joaquin Local Hen .. District. <br /> JOB ADDRESS/LOCATION / 3 CENSUS TRACE <br /> i <br /> a••ner'a Name Phone <br /> Wdreasrr� _ -- <br /> �;G.i /r/ �/ . G+S ��b City <br />,ontractor's Name - <br /> `J� - Licenr.e I - Phone <br />'YPE OF WORK (Check)t NEW WELL L7 DEErE:N /+� RECONDITION /7 DLS'rRUCTION n <br /> PUMP INSTALLATION /7 pump REPAIR LV PUMPRF.PI,ACEMNT L-7 <br /> Other <br /> IISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ N PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPACF, PIT OTHER \ + <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL __ euBLIC DOHF.STIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS iv <br /> Industrial Cable Tool Din. of Well Excavation <br /> Domestic/private Drilled Eli. of Well Caning <br /> Domestic/public Driven of Casing <br /> Irrigation Gravel Pack Depth of Grout Sial <br /> Cathodic Protection Rotary Type of Grout + 1 <br /> Disposal Other Other Information <br /> Geophysical % Surface Seal Installed By: v <br /> UMP INFfAL_ LATION: Contractor <br /> Type of Pump / let _ „ ' ..`___ H.P. _ <br /> L111P REPLACEMENT: L-T State Work Done <br /> JMP REFATR: /x� State Work Done <br />:S RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ---- <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />.ter completion of my work on a new well. I will furnish the San Joaquin Local Health District a <br />:LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />►formation is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br /> QN <br /> IOR TO GROUTING AND A FINAL INSPECTION., + ` <br />:GNED r: a - / . /� ! \ TITLE <br /> PLOT PLAN ON VERSF. SIDE <br />;ASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY ,t DATE <br />,DITIONAL COMMENTS: <br /> PHASE II GROUT SPECTION PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION B DATE / <br /> E H 1426 Rev. 1-74 � • ' 7t,/75 219 _73 <br />