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n� SAN JOAqulN LOCAL' IIEALTH DISTRICT <br /> FOk'iOFFICEUSE: 1601 E. Hazelton Ave. .Stockton, Calif. <br /> Telephone: . °(209) 46667$1 <br /> APPLICATION foie WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72_, j_uJ <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issuedd-�-7 <br /> jcomplete In Triplicate) <br /> App Sed ivri..is hereby made to the Ban Joaquin local- Realth District for a permit to construct <br /> and/..or .install the .work herein described. .,Tihis 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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone —00 10I <br /> Owner's Name <br /> Address - w. City lJ <br /> Contractor's Name_ _ r ° -w-- -•-r- -License--#- -Phone-LiG2w� ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/� RECONDITION I-T DESTRUCTION - <br /> PUMP INST CATION El PUMP REPAIR /7 PUMP REPLACEMENT <br /> t Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /410, - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 70 <br /> s } Domestic/private Drilled Dia. of Well Casing <br /> �T-'- Domestic/public Driven Gauge of Casing <br /> Irrigation # Gravel Pack Depth of. Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other. Other Information <br /> Geophysical. -ry Surface Seal Installed B <br /> r PUMP INSTALLATIONZ. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work-Done- -, -- <br /> PUMP `.REPAIR: /7 State Work Done <br /> Approximate Depth <br /> E&TRUCTION OF WELL: Well Diameter pp <br /> Describe Material and Procedure <br /> i ` <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_befoie_putting­the..well i_n.use.. The above_._ <br /> information is true -to- the­.beet of-my}knowledge and belief: I WILL CALL FOR'A 'GROUT INSPECTION <br /> PRIOR TQ GROUTING AND A,)FT4a INSPECTION. <br /> SIGNEDTITLE <br /> �-4OXe.4RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / - ,� - 7 INSPECTION' BY DATE / ` 4 '7_ <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />