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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE '-ICE USE: 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. 72, c77&t <br /> �} 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 ,2v2,j <br /> 7u Guoo� L � Ga9ia� �z. CENSUS TRACT <br /> Owner's Name F3yis J 41irnn2s <br /> r� / ..,..,.., Phone � ?s-os— <br /> Address �2 5'�7 ,[S 4e e wawa 2IW61 <br /> i City ��-CAcv.✓ (�z�J� <br /> Contra �r's Name J <br /> j License # �I `�Phone �-f <br /> TYPE OF WORK (Check); NEW WELL/DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE 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 SPECIFICATION , <br /> Industrial Cable Tool Dia. of Well Excavation <br /> domestic/private (. rilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing _ ` <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Cathodic Protection l/ 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. <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP .REPAIR ' _ V <br /> State -Work Done <br /> ES-TRUCTIOWbF WELL: Well Diameter Approximate D : <br /> Describe Material a d Procedure <br /> f I hereby agree to comply with all laws and regulations of the Sats 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 INSPECTION <br /> PRIOR TO G ING AN> A FI INSPECTION. <br /> SIGNED TITLE <br /> DRAW T PLAN ON REVERSE SIDE) <br /> FO /DEPAJZTMENT USE ONLY <br /> PHASE I ' J <br /> PPLICATION ACCEPTED BY / DATE r <br />. AADDITIONAL COMMENTS: C7 i <br /> PHASE _I GRO T INSPECTION PHASE IN AL INSPECTION <br /> INSPECTION BYDATE 7 INSPECTION BY DATE. i <br /> :r l <br /> E H 1426 rl Rev. 1--74l -�`� � :, 376 2M <br />