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SAN JOAQUIN LOCAL HEALTH. DISTRICT _ <br /> rOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.72 /Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �. 0 ��s^. A��., �� CENSUS TRACT <br /> Owner's Name f Phone -- <br /> AddressCity <br /> Contractor's Name � � License # Phone <br /> z <br /> TYPE OF WORK (Check) : NEW WELL/W DEEPEN '/—/ RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -:�C7-k- 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 Driven Gauge of Casing <br /> Irrigation -Gravel Pack Depth of Grout Seal -4-4) _ <br /> a _ <br /> Cathodic Protection �_,g,,_-Rotary x _ Type of Grout '~ oi <br /> Disposal t Other. Other Information <br /> Geophysical } Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �.j"�„� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTIONOF WELL: Well Diameter - Approximate Depth <br /> DescribefMaterial and Procedure <br /> I hereby agree to comply with all Taws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'constructi.on. Within FIFTEEN DAYS a <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 well and notify them before putting the..well in use. The above <br /> information is the b_es.t�of y k gwledge and belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO GROUT e AL INS . 6NI <br /> SIGNED It TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _M DATE <br /> ADDITIONAL COMMENTS: <br /> P S II G OUT INSPECTION PHASE /FINAL INSPECTION <br /> 4 0A <br /> INSPECTION BY DATE INSPECTION BY DATE ��a <br /> f <br /> 1177 <br />