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:F SAN JOAQUIN LOCAL HEALTHb.DIST_PICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,72 <br /> � 0 THIS PERMIT EXPIRES 1 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 I'AB-*0 ef, J?W CENSUS TRACT <br /> Owner's Name 'P � Pk s oVd r a d1 Phone <br /> Address o '7 /{i W 0i].c� _.__ City f-cg/oe) <br /> Co'ntractor's Name L/gllez Dom, Ccs License It,? Phone -1/ A,S' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> e <br /> DISTANCE TO NEAREST: SEPTIC TANK j�w SEWER LINES 141D PIT PRIVY <br /> F SEWAGE DISPOSAL FIELD CESSPOOL/SEEP GE PIT OTHER <br /> PROPERTY LINE1° PRIVATE DOMESTIC WELL J-.T-! PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> v <br /> Industrial- Cable Tool Dia. of Well Excavation 12 Y ,` <br /> - Domestic/private Drilled Dia. of Well Casing ( '/ <br /> Domestic/public Driven Gauge of Casing JXe7 Pf 4 <br /> Irrigation Gravel. Pack Depth of Grout Seal 6-01, 1\ <br /> Cathodic Protection. *1 Rotary Type of Grout PP, e <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : P PUMP INSTALLATION: ContractorType of Pump H.P. <br /> 7=1 <br /> FUMP REPLACEMENT: / / State Work Done I <br /> f <br /> PUMP .REPAIR: / / State Work Done <br /> 1 <br /> DESTRUCTION 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 thewell 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 GROUTING AND A FINAL IN ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE 7 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> P GROU INSPECT ON PHASE T. ZI [FINAL INSPECTION <br /> INSPECTION BY DATE 2 d INSPECTION BY / //' ATE '` 011 <br /> S�d�. h a 1 <br /> 6 2M <br /> R H 1426 RF-w. - I-74 <br />