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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-�y 94 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l_0-/L28' , ; <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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' x c <br /> � � s <br /> Owner's Name Phones <br /> Address .. <br /> rJA0 City <br /> Contractor's Name License # /3 Phone - <br />'~TYPE-OF WORK (Check) :' NEW WELL A7 DEEPEN %/ RECONDITION <br /> PUMP INSTALLATION / / PUMP REPAIR./ / PUMP REPLACEMENT /7 <br /> Other /_7 <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 TYPE OF WELL CONSTRUCTION SPECIFICAT ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 'Z64, <br /> Irrigation Gravel Pack Depth."ofGrout Seal <br /> Cathodic Protection rotary TypeofGrout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT f_1 State Work, Done <br /> PUMP .REPAIR: ;/ / State Work Done DES-TRUCTION OF WELL: Well Diameter*. -Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall IAws,, and regulations ,of the San Joaquin Local Health District <br /> and the State of California pertaining 'to .:or regulating*well -construction. Within FIFTEEW DAYS <br /> after completion of my work on .a new we11;:sI will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of theell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WIL L F GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FIN .sINSPECT <br /> SIGNED &AIM 'TITLE , <br /> DRAW:Pig PLAN ON REVERSE 5 ) t. <br /> ,FOR?9EPARTWENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: //, z/�� - <br /> PHA,$E I. �t�INS EgIQN PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATECZV_ INSPECTION BYR DATE 2,�+-_ <br /> EH� 1426 Rev.' 1-74 3/7 . , <br /> ' <br />