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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh,OFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. b <br /> Telephone: (209) : 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT , Permit No. 72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued fo } <br /> (Complete In Triplicate) _ <br /> Application is h'ereb <br /> y 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 Regula io s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name i Phone <br /> Address <br /> City 6a, (,MAI <br /> *_-License--#_ Phone, .3 �" , <br /> TYPE OF WORK (Check) : NEW WELL Imo/ DEEPEN / / RECONDITION /_7 DESTRUCTION /_7f PUMP INSTALLATIONF / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY 1 , <br /> r SEWAGE DISP OSAL FIELD/CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY- LINE PRIVATE DOMESTIC WELL PUBLIC#DOMESTIC WELL <br /> INTENDED_ USE TYPE-IO WELL X <br /> __ CONSTRUCTTON,SPECIFICATION <br /> Industrial ,. q Cable Tool Dia, of Well Excavation <br /> Domestic%private Drilled Dia. of Well Casing ' s <br /> JL <br /> Domestic/public. $ Driven Gauge of Casing � �^ <br /> Irri ation <br /> g Gravel Pack Depth of Grout Seal 1. --- <br /> Cathodic Protection " ..Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical <br /> "` ""- :; a Surface Seal. Installed By <br /> : <br /> PUMP INSTALLATION: Contractor1�` //1g/77 <br /> Type of Pump d '7 H.P. <br /> PUMP REPLACEMENT: / / State Work Done x �' <br /> PUMP '.REPAIR: State Work Done t <br /> i f <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 DAIS <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 est of my knowledge and belief.' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR I G AND <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEr It <br /> FOR ARTMENT USE ONLY <br /> PHASE I f I' <br /> APPLICATION ACCEPTED BY x DATE (/ Z F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. , �•� PHASE.JAA/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 - y 1177 )4 <br />