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I! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> K.*OFFICE USE. 1601 E.-Aazel;on Ave.., Stockton, Calif. <br /> Telephohe: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-30 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued A1__0- � <br /> 't (Complete In Triplicate) <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 andjthe Rulea and -Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z9 CENSUS TRACT ' <br /> Owners Name Phone <br /> Address City <br /> Contracto 's Name , License.# �chone <br /> r <br /> TYPE OF WORK (Check): NEW WELL / T DEEPEN ,/7 RECONDITION DESTRUCTION /_7 � <br /> PUMP INSTALLATION / / PUMP REPAIR'/-7 PUMP REPLACEMENT f f s <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 4 Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �~ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> k Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br />'t Geophysical rF j� Surface Seal Installed 'By: <br /> PUMP INSTALLATION:' Contractor 49-rr . ' <br /> Type of Pump —71 H.P. <br /> PUMP REPLACEMENT: . %/ State Work Done <br /> PUMP :REPAIR: / / State Work Done j <br /> 4 DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 'zonstruction. Within FIFTEEN DAYS <br /> after completion of my work �bn a new well,.,.I will furnish the San -Joaquin Local Health District a <br /> i 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 TO GROUTING AND A FINAL INSPECTION. ' 4 <br /> SIGNED TITLE' <br /> f (DRAW PLOT PLAN- ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS: + <br /> PHASE II GROUT INSPECTION PHAS ' I I FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> R R 147A Raw_ 1_74 __ <br />