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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , F��,� ICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ,. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -72-,33d k1 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> f Owner's NameA019 Phone <br /> C <br /> j AddressA City <br /> 4 <br /> Contractor's NameAMWCL 4 17 IAcense #)&Uj Phane,,S� <br /> F am EEC F <br /> TYPE OF WORK (Check)S i.- WELL RECONDITION /7 DESTRUCTION <br /> PUMP INST LL TION / / PUMP REPAIR -L-7 PUMP REPLACEMENT /—f <br /> i:Other../ /J -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4_ 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. Pack Depth of Grout Seal �d � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information " <br /> Geophysical Surface Seal Inst <br /> al3ed B <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type. .of Pump I.P. <br /> PUMP REPLACEMENT: J7 State Work Done <br /> PIE .REPAIR: 17 State Work Done <br /> � RES�TRUCTION 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 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 rue tot •best .ofy. knowledge and belief. I WILL CALL FOR A GROUT- INSPECTION <br /> PRIOR'TO GROU I G AND A"` AL IN , ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � - � _ <br /> APPLICATION ACCEPTED BY1DATE <br /> . ADDITIONAL COMMENTS: <br /> PHME II ROUT INSPECTION P SEIIINAL INSPECTION <br /> INSPECTION <br /> DATE J <br /> B DATE <br /> E H 1426 Rev. 1-74� ;" ' W75 2M <br />