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*- L `� �C31► 'S N JOAQUIN LOCAL REALTH 'DISTRICT <br /> FOIA rf� _ICE USE: 1601 E. Hazelton Ave. , Stockton, `Calif. <br /> `. - I Telephone: (209) 4666781 - . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- ,72 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)- <br /> Application is hereby made tolthe Set: Joaquin Local Flealth: 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 andithe Rules and Regulations of the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 2— <br /> Address 1._a' City M- <br /> Contractorts Nam License # tL-7W­Phone � <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /? DESTRUCTION /7 ! <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /-T <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 t Cable- Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing" <br /> Domestic/public Driven Gauge of. Casing <br /> Irrigation 1 Gravel Pack Depth of-Grout Seal <br /> Cathodic Protection ;# .Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical. Surface Seal-Installed By-:. <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. oo <br /> PUMP REPLACEMENT: / / State Work Done <br /> P!NREPAIR.-- /jtf... State-Work=.-Done60Z==: _ <br /> E&TRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> ,r <br /> I hereby agree to comply with all lawns and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS j, <br /> After completion of my work ou 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 the best of my-kncW]-ejdrge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIORTO ZING D A FINAL P - , <br /> SIGNEDA6e ITLE 1' , <br /> eor LOT PLAN ON MVERsE SIDE <br /> FOR--DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE p <br /> f 1 9r-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S T NAL TNSPECTION <br /> INSPECTION BY INSPECTI Y DATE —3D-� <br /> E E H 1426 Rev. 1-74 1-74 2M <br />