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c ' <br /> s L' SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-2--U,k) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�_��-r�7 <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 applicatioir 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 Iv <br /> CENSUS TRACT ' <br /> Owner's Name <br /> G��-d� Ph one 3�P^b Z f <br /> Address [s; City <br /> Contractor's Name License 6123 3 Phone3e' i?� <br /> TYPE OF WORK (Check) : NEW WELL & DEEPEN '/—/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _-;13 SEWER LINES SZ ` 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 _ M. Cable Tool Dia. of„Well Excavation <br /> Domestic/private Drilled '' ' °?' Dia.=of Wei1�Casing <br /> Domestic/public Driven:,- .-- Gauge of Casing <br /> Irrigation 'Gravel- Pack Depth of Grout Seal or <br /> Cathodic Protection Rotary Typey;of Grout <br /> Disposal Other., - Other ,Information ' .— - <br /> Geophysical �, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .. <br /> Type of Pi uip, H.P. <br /> PUMP REPLACEMENT: /% ',.,State Work Dane <br /> PUMP .REPAIR; State Work Done <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 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 I ANDINAL IN ECT ION. <br /> SIGNED TITLE <br /> RAW PLDT`PLAN ON REVERSE"SIDE) 7 <br /> PHASE I ZJFOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE It GROUT INSPECTI N PHAS II/ INAL INSPECTION <br /> INSPECTION BY --�� DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 {� 3/76 2M <br />