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;AN JOAQUIN LOCAL HEALTH DISTR _ <br /> FOfi OFFICE USE: + 16`61 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 77.30j/1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;72-.Z_?5—Z6) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Ieeued3— 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 application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and <br /> Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ���c3� �' X� J`r/9CENSUS TRACT <br /> Owner's Name ;� T Phone <br /> Address /�j_� 1Y> ��� City <br /> Contractor's Name 4 &�, 2 LXi ' License Il i) � e YPhone f� f— <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION K1 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK jo-Q_` 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 �ble Tool Dia. of Well Excavation j 4 <br /> //Domestic/private Drilled Dia. of Well Casing , O <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth 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 <br /> Type of Pump H.P. O1 7, � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ; <br /> )ESTRUCTION 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 thuell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTIN D A F 10 } <br /> 31GNED *Y TITLE <br /> _ DRAW PLOT PLAN ON REVERSE,SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ?RASE I <br /> UPLICATION ACCEPTED BY DATE Z <br /> %DDITIONAL COMMENTS: <br /> PHASE II .GRgUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY a DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1,/7K 9M <br />