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r ✓' SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a- <br /> (Complete in Triplicate) <br /> Application is hereby made to the san Joaquin Local Health isistrict made inrcompllancetwith SamconstruJoaquin <br /> and/or install the work herein deet <br /> I <br /> and t e. Ruesan�d�{FRegulations of the San Joaquin Local Health District. <br /> County Ordinance Na. 1$6 � <br /> •' rC&LAI s CENSUS TRACT <br /> JOB ADDRESS/LOCATION V <br /> Phoneme �--C) C,pwner`s Name ��. <br /> City <br /> Address .� { <br /> t' A License # "U!0 Phone <br /> 'Contractor's Name - <br /> t TYPE OF WORK (Check): NEW WELL / nE P /?� RECQNDITION. /? DESTRUCTION ' ' <br /> PUMP INSTALLATION,jLI'�PUMp REPAIR",,/ PUM REPLACEMENT , ./ <br /> Otherr- <br /> SEWER I,#NES IT PRIVY:. <br /> DISTANCE TO NEAREST: SEPTIC TANKS I � —g <br /> SEWAGE DISPOSAL FIEL �1 - CESSPOOL/SEEPA E PIT _ OTHER <br /> PROPERTY LINE RIVkE .DOMEST.IC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.'�of,.Well Excavation <br /> stl i / 4 <br /> k ndustriaprivate Drilled Dia. ofd Well Casing <br /> Domestic/Public Driven" Gauge o€-Casing <br /> r <br /> Irrigation .�..- Gravel, ]Pack Depth of-Grout <br /> a of Grout <br /> . Cathodic Protection Other 1,—,Other Information <br /> ,w e <br /> Disposal Su" a Seal Installed- B <br /> t Geophysical <br /> .�. �'� y <br /> PUMP INContractorSTALLATION: H.P. <br /> Type of Pu i r <br /> PUMP REPLACEMENT: ,, , <br /> %// State Work Done - -" <br /> _ <br /> PU : `, / State Work Done <br /> MP .REPAIR: �., <br /> `Y _T a A, Approkiniate Depth <br /> DES-1RUCTION OF WELL: .,�4 Well Diameter <br /> D6scribe-.Material and Procedure,2 _ yl <br /> i 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 `di regulating well construction. <br /> Within FIFTEEN DAYS <br /> after completion of my work4-on - new well, I will furnish the San Joaquin Local Health District s. <br /> f WELL DRILLERS REPORT of the we11 and -notify-them before putting-the well in use.. The above <br /> k in ation is true to the-bes f knowledge and belief. I WILL CALL FOR A`GROUT INSPECTION <br /> I PRIOR GROUTING AND A FI 10 TITLE .� <br /> SIGNEDDRAW PLOT PLAN ON REVERSE SIDE <br /> l FOR DEPARTMENT USE ONLY <br /> f ,PHA / DATE - S <br /> APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: .._ P III INSPECTI N <br /> P E I GROUT INSPECTION INSPECTION B �DATE <br /> INSPECTION BY DATE �.� <br /> k J. - <br /> { �4 E H 1426 Rev. 1-74 1-74 2H <br />