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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: C 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telr.phone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIOU OR PUMP PERMIT Permit No. 72-ja 9/)o <br /> 'CHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issu_d <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 nide in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> R <br /> JOB ADDR.?SS/LOCATION 1�_r��? �' l CENSUS TRACT <br /> } Owner's Name ZA, Phone <br /> i <br /> Addre_.. , 9i � City e-- <br /> Contractor's Name �7,V,i<t?S.0/ V���n ,7.�,C,1J� l�� <br /> _ Licensa /5L7l / Phone 5X� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUK- :.EPAIR /21'— PUMP REPLACEMENT /7 <br /> i Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL MELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LINE - PRIVATE JOMESTIC 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 /> i v Irrigation _ Gravel Pack Depth of Grout Seal <br /> Y Cathodic Protection Rotary Type of Grout (�} <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor L n,; -I ^'-e7 <br /> Type of Pump 7`1 R h t --v— -r H.P. /s <br /> PUMP REPLACEMIT: / / State Work Done <br /> PUMP .REPAIR: / / State ',fork Done �/ �/ �,� , ,N,�, ,e -e <br /> DES-TRUCTTON 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 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 CP.OUTING MD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' , <br /> APPLICATION ACCEPTED BY �C'�ir�t�-!` DATE <br /> 1 '// 2 Z_ <br /> ADDITIONAL COMMENTS: <br /> ?RASE II GROUT INS?ECTION PHASE III/FINAL INSPECTION <br /> !NTS?ECTION BY DATE I`ISPECTION BY DATE <br /> E :i 1426 Rev. 1-74 3/76 2M <br />