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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: m � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-M <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) <br /> j 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 � p �. CENSUS TRACT <br /> Owner's Name 1 Phone <br /> Address <br /> City <br /> Contractor's NameQ License kAF604t>g Phone <br /> t <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 /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial { Cable Tool Dia, of Well Excavation <br /> E, ...---..Dome s.tic/-private... - _ Drilled _ Dia.--of--Well-Casing. -- -- -- =--- <br /> Domestic/public Driven Gauge of Casing s_ <br /> Irrigation— _ _ ! Gravel Pack` Depth of Grout Seal <br /> E Cathodic Protection # Rotary Type of Grout <br /> E <br />` Disposal t Other cOther Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br />� PUMP REPLACEMENT: �. State Work <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL,: Well Diameter Approximate Depth <br /> E 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 we11 '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 /> WELT. DRILLERS REPORT of the well and notify them before putting the. well in use. . The above <br /> information is true to e best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING Jr INSPECTION. <br /> SIGNED TITLE <br /> k (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE gyp--7�-Z <br /> ADDITIONAL COMMENTS: 1' <br /> PHASE 11 GROUT IN CTION PHASE,,,1jI/FI3AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r Q <br /> E H 1426 Rev. , 1-74 T n��l7 _ 2M <br />