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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF ;OFFICE USE: 1601 . Hazelton Ave. , Stockton, Cal <br /> 'Telephone ; (209). 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 72-116711-' <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 I� Ordinance No. 1862 and the RulA�andd Regulations o£ the San as in Local alth rict. <br /> JOB ADDR �S/LOA N �� <br /> '`�"`-� � CENSUS TRACT <br /> _ <br /> (7cmer;'s Name Phone <br /> Address �J c2 3 Cit es -- <br /> [,' y <br /> Contractor's Name <br /> License # 4!�64_Phone - <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 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL _—_. PUBLIC DOMESTIC WELL <br /> INTENDED USE J TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ;,Industrial Cable Tool Dia, of Well Excavation <br /> fl3omestic/private Drilled Dia, of Well Casing <br /> [Domestic/public <br /> Driven <br /> 4�Irri ation Gauge of Easing <br /> j g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther Information <br /> Geophysical Surface Seal Installed By: <br /> f; <br /> PUMP INSTALLATION: Contractor 67kec.� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q <br /> _V <br /> State Work .Done <br /> t�. <br /> PUMP REPAIR: State Work Done <br /> ;s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with al]_ 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 puttingthewell 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 GRO �INGAN NAL INSPECT UN. <br /> SIGNED+ <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY Com/ p, <br /> DATE O�7� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTTON BY DATE - 77 <br /> IF [ <br />