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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, Cali .. <br /> Telephone: (209) 466-6781 Permit N;�. 72-� 3P <br /> i" <br /> APPLICATION FOR WELL CONSTRUCTION OR <br /> PUMP <br /> ed �//-7 7 . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issu � <br /> r <br /> it (Complete In Triplicate) <br /> ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit twith Sa J <br /> pP lication is made in compliance with San Joaquin <br /> and/or install the work herein described. This app <br /> County <br /> Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local <br /> Health District. <br /> ICENSUS TRACT <br /> r <br /> JOB ADDRESS/LOCATION <br /> ra'` <br /> Phone <br /> ! Owner's Name <br /> City <br /> f Address �iphone <br /> _ y <br /> I License # - <br /> Contractor's Name <br /> 1 <br /> iDESTRUCTION /_7 <br /> RECONDITION_I / <br /> r TYPE OF WORK (Check} : NEW'WELL I I DEEPEN PUMP REPAIR / / PUMP REPLACEMENT 1i <br /> PUMPS INSTALLATION y <br /> Other V/ 'I <br /> .PIT PRIVY <br /> SEWER LINES OTHER <br /> DISTANCE TO NEAREST:' SEPTIC TANK _�� CESSPOOLISEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL —w- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL" <br /> Cable Tool Dia. ofWe11 Excavation <br /> { Industrial Drilled . Dia. of Well Casing \ <br /> Domestic/private <br /> Driven.. <br /> } iven ,. �:` Gauge of Casing <br /> Domestic/Public Depth of Grout Seal <br /> t Irrigation � Gravel_.,Pack p <br /> Rotary Type of Grout <br /> ► Cathodic Protection y' <br /> r r s Other Other. .Information <br /> Disposal Surface Seal. Installed B <br /> —Geophysical 2 <br /> PUMP INSTALLATION:: Contractor <br /> //6 H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ��/ State Work Done <br /> i y State Work Done <br /> PUMP .REPAIR: I <br /> j Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure j <br /> e to comply 'with all laws and regulations of the San 3oaquin Local Health District <br /> EEN <br /> I hereby afire <br /> State of California pertaining to or regulating WethecSantJoaquin.Local HealthWith, TDistDrict <br /> and the ; <br /> after completion of my work on a new well, I will furnish te .well in above <br /> WELL DRILLERS REPORT of the well and notifye em ndfore putting thbelief. I WILL CALL ORuAeGROUTeINSPECTIOr <br /> information is true to thebeSINSPECTION my. kn�wl g <br /> PRIOR TO GROUTING AN Of <br /> TITLE <br /> SIGNED DRAW Pi. T PLAN `ON REVERSE SIDE) 1 <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE /`� <br /> APPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS: r PHASE /FIN INSPECTION �-- <br /> PHASE II GROUT INSPECTION INSPECTION BY DATES 7 / <br /> INSPECTION BY !� DATE ' <br /> l 3/76 2M <br /> F R 1426 Rev. 1-74 <br />