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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-sg11 e <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y-/ 7 <br /> (Complete In Triplicate) 11 <br /> Application"is Aereby1made 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 L�' g r �' �f2 CENSUS TRACT <br /> �... r. <br /> Owner's Name -TC-0Phone ' <br /> Address, _.. A 1z City:T d c/�T�A <br /> Contractor's Name ve a SfA License # Phone <br /> - E I <br /> TYPE OF WORK (Check) NEW WELL /a/ DEEPEN / `J"PRECONDITION ,`j. / DESTRUCTION <br /> i PUMP INSTALLATION/ PUMP REPAIR / f PUMP REPLACEMENT /! <br />` Other <br />' DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> :. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .�� PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />` IINTENDED..USE—---- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation r O <br /> Domestic/private. f 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 B <br /> PUMP INSTALLATIONt Contractor fie` C <br /> Type of Pump H.P. `ate --- <br /> PUMP REPLACEMENT / / State Work Done , <br /> PUMP .REPAIR: / / State Work Done <br /> } <br /> }DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe- Material and Procedure <br /> F <br /> � I hereby agree to comply with, all laws and regulations of—thd' 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> Minformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ''PRIOR TO GROUTING ANDA INAL INSPECTION. <br /> SIGNED rAIN TITL _ --i <br /> (.DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f-77 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ,. .._ . .-..-.PHASE,•-II,GROUT=I-NSPECTION,--, "' ""'PHASE ISI/FINAL INSPECTION <br /> k INSPECTION BY DATE ": *" -I.NSPF,,CTION-BYy DATE <br /> rU77 2M <br /> E H 1426 Rev. 1-74 ---- <br />