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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.72:" /_ j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedcf- 3 <br /> (Complete In Triplicate) - <br /> Application is ►ereby 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 and th Rules a Re ulatio of_ the San Joaquin Local Health District. <br /> /�. <br /> JOB ADDRESS/LOCATION '/ CENSUS TRACT _ <br /> Owner's Name �� Phone 5 3" <br /> If <br /> Address City <br /> Contractor's Name r License 19z44�Phone <br /> I TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /_7 DESTRUCTION /7 T <br /> PUMPJINSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT uOTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ;TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; Lr <br /> Industrial 1 gCable Tool Dia, of Well Excavation r <br /> Domestic/private C Drilled Dia. of Well Casing <br /> Domestic/public ;I Driven Gauge of Casing <br /> Irrigation -: t Gravel Pack : Depth of-Grout Seal <br /> Cathodic Protection - 1 -Rotary Type- of Grout <br /> Disposal I Other Other Information <br /> -•�, Geophysical f. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> a: - <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / ?State Work Done <br /> a` <br /> 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 regal°sting 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 thelwell and notify them'•bfefore 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 GROIZIU, MD A FINAL IN PE IO <br /> SIGNED TITLE _ _._... <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I � <�3 G_' 7 7 <br /> f APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUTiINSPECTION PHASE /FINAjv INSPECTION <br /> INSPECTION BY ; DATE INSPECTION BY DATE - o <br /> I j f77 _ 2 <br /> E H 1426 Rev. 1-74 <br />