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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> M , <br /> EGF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT et'�� No. 72- 31-- IO <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .11-7- <br /> A <br /> `7;A (Complete In Triplicate) f <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 nd Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ",9 IV,/ ,,4 Aj CENSUS TRACT <br /> Owner's ,Name e� 'r-� Phone <br /> Address &Z City '. <br /> Contractor's Name `teLicense #.�)&4 Phoned <br /> TYPE OF WORK (Check):' '•NEW WkL. \/_7 DEEPEN /7 RECONDITION /? DESTRUCTION � r <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 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 s <br /> Irrigation 1 Gravel Pack Depth of Grout ;Seal <br /> Cathodic ,Protection `S Rotary Type of Grout <br /> Disposal a Other Other Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. !" <br /> PUMP REPLACEMENT: / f State Work Done cE.2.c l <br /> PUMP �.REPAIR: / / State Work Dane <br /> DESTRUCTION OF. WELL: Well Diameter r• Approximate Depth <br /> Describe Material and --Procedure <br /> • 6 <br /> I hereby agree- to complywith all laws and-regulations"of the San Joaquin Local Hea th'District <br /> and the .State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> atter 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 `Uiifore 'putting the well in use. The above <br /> information is"true to the best of my knowledge and belief. I WILL CA14L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION:'�� _i"' <br /> SIGNED TITLE <br /> p (DRAW PLOT PLAN ON REVERSE SIDE <br /> f FOR ARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II/ NAL INSPEC119A. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 <br /> : 1177, _ 2M <br /> ' E H 1426 Rev. 1-74 <br />