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p SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 72- ,T AJ <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7 2 , <br /> (Complete In Triplicate) d <br /> ' Application is hereby 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 andel the RulesandRe ulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION �g 9 CENSUS TRACT <br /> Owner's Name 2:nyl 1'5 -e- Phone l3� 3/6" 7 <br /> Address e City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / ./ DESTRUCTION - <br /> PUMP !INSTALLATION I I PUMP REPAIR / / PUMP ,REPLACEMENT /? . <br /> Otherf <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 i Driven, Gauge of Casing' ' 1 <br /> Irrigation Gravel Pack Depth of Grout Seal \��U <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information' - <br /> Geophysical Surface SealInstalledBy: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth• ( Q <br /> Describe Material and rocedure Za 5-0 <br /> 1 herebya <br /> 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 /> I� 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION, <br /> PRIOR K0j!�MTIHR=LWD A FINAL INSPECTION. <br /> SIGNED <br /> TITLE _ <br /> r <br /> DRAW PIDTPLAN 'ON. RSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> k APPLICATION ACCEPTED BY _ _ , DATE / 3U <br /> 1 ADDITIONAL -COMMENTS: ! w <br /> PHASE II GROUT I1gS CTION � � PHASE III FINAL INSPECTIOZ. <br /> INSPECTION BY DTE a 2NS ECTION BY DATE <br /> E H 1426 Rev. 1-74 � I v� �� /f-�'�� 3/7 22U <br />