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/Z V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6-�L �c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> .pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ,..,nd/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 /> OB ADDRESS/LOCATION /8.50 Hn ZZ % h:j0S T Pci � P � CENSUS TRACT <br /> Owner's Name V/ f?n jL R RL n Phone <br /> 4:ddress S#4)-� City �rsele+ cash <br /> ontractor's Name T f? $, A, �. License #% Jv Phone Fri U7 <br /> r <br /> -YPE OF WORK (Check) : NEW WELL /-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT % f <br /> Other /% Z- A, . <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 <br /> Industrial Cable Tool Dia. of Well Excavation O <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. a <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> _W .REPAIR: State Work Done C ngN6E n j ` VjoZ l� <br /> PILSTRUCTION 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 /> id the State of California pertaining to or regulating well construction. _Within_FIFTEEN-DAYS- <br /> �;-re-r comp on of my wor 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 /> '-iformation is true to the best of my knowledge and belief. I WILL CALL FOR AGROUT INSPECTION <br /> S 'IOR TO G Q TING AN AA FINAL INSPECTION. <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 'P14ASE I FOR DEPARTMENT USE ONLY <br /> APPT ICATTf1N- ACGE mvTDATE _ _ <br /> _ 01TIONAL-COMMENTS: -- - -- -- <br /> PHASE II GROUT INSPECTION PHASE II N INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> .� ,� DATE <br /> r. E H 1426 Rev. 1-74 <br />