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ill SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -TO-r,-"OFFICE USE ` J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72- IK-277 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is deby 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. 18/62 and the Rules and Regulations f the <br /> ,, llSan Joaquin Local Health District. <br /> JOB ADDRESS/LO ON / - , Gam' CENSUS TRACT <br /> Owner's Name Phone e _ , -75z7 <br /> Address ._ City iG <br /> Contractor's Name L-/ 4 '* Ucense IORO 4 Phone o �� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /_7 DESTRUCTION /_ <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 SPECIFICATIONS �, <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 PackDepth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor�Ji <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done,-t-/- <br /> PUMP -.REPAIR: <br /> one ;PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 Distri <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAY <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 /> information is tree LQ, the best of my knowledge and belief. I WILL CALW FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AN AFI AL INS ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,!� { <br /> APPLICATION ACCEPTED BY f7 ' "� <br /> �-�-a- .-x. .4�A DATE ,'�``-, ,,• � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY li,> DATE -lo, -77' <br /> E H 1426 Rev. 1-74 <br /> 1777 2M <br />