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w / r ori <br /> SAN JOAQUIi��.,0CAE HEALTH DISTRICT , <br /> E'O�,@PFICE USE: ' � 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-72-� <br /> G(J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x Y`/-7 <br /> (Complete In Triplicate) <br /> Application is..Aereby 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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p CENSUS TRACT <br /> Owner's. Name J�� - Phone <br /> Address <br /> City S�� <br /> Contractor's Name License it& <br /> 4UIPhone <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN/ / RECONDITION 'DESTRUCTION /-7. <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE .TO NEAREST: SEPTIC TANK ' SEWER LINES,&g� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEV40PRIVATE DOMESTIC WELL/Q ` PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ V Cable Tool Dia, of Well Excavation 42 <br /> Domestic/private Drilled $ Dia. of Well Casing' 14 <br /> Domestic/public Driven `. Gauge of Casing 1244 <br /> Irrigation T Gravel Pack.. `,Depth of Grout Seal <br /> Cathodic Protection Rotary- _ Type of Grout ,,, , E <br /> Disposal Other Other Information <br /> Geophysical '- Surface -Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> pESTRUCTION 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 the well in .use. The above <br /> information is true to th t of m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GR T G D A F Nb IN E" TjoNT <br /> SIGNED TITLE „� J <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASY, IXI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />