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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72- f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7j <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 Jo4quini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> AJ: 07/-a - `f i <br /> JOB ADDRESS/LOCATION /I4/L:E �(�, Ldej T 0 G CENSUS TRACT <br /> Owner's Name S 41- Phone 7/'�"-�G� l5/c,�p <br /> Address x City //, -)sS 7 alo� <br /> Contractor's Name License # Phone <br /> 6 <br /> TYPE OR-WORK- (Check) : NEW WELL '/—/ DEEPEN/ / RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR J / P PLACEMENT /_7 <br /> OP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER - 1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL i PUBLIC DOMESTIC WELL � 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <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 �y Rotary Type of Grout <br /> Disposal Other Other Information <br /> _Geophysical t Surface Seal Installed B, : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. # <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done p <br /> DESTRUCTION OF WELL: Well Diameref, -= "` Approximate Depth <br /> Describe Mat rial n Procedure <br /> I hereby agree to comply with all claws 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 INSPECTIO <br />?RIOR TO GRO NG AND eFIUL PErCTIO . <br /> SIGNED TITLE :+I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> F R DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ - DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE"II GROUT INSPECTION �"`-"'-F^-1--�.-: V PHASE III/FINAL.INSPECTION <br /> INSPECTION BY DATE INSPECTION-BY--m DATE <br /> E H 1426 Rev. 1-74 4�"`. 1 <br />