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SAN JOAQUIN LOCAL HEALTH 'DISTRICT <br /> FORFF CE USE': / 160 . E. Hazelton Ave. ,, Stockton, Calif. 1 <br /> Telephone: (209) 466-6781 <br /> ..- I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. QIP <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 mock herein described. This application is made in compliance with San Joaquin . <br /> County Ordinance No. 1862 and the Rules and Regulations of the San on Local Health District. <br /> h)efJOB ADDRESS/LOCATION , M'�aa ,� d A,f d K SUS TRACT <br /> Owner's Name • �g ,. Phone <br /> Address p city � ► <br /> Contractor's (Name40 — License # Phone <br /> TYPE OF WORK ((Check) : NEW WELL/ / DEEPEN/_/ RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR /�C/ PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NW EST: 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 Driven Gauge of Casing N <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Sdrface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. !` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR; JL</ State Work Done 141- <br /> DESTRUCTION 0 WELL; Well Diameter _ Approximate Depth f <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 Statelof California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin .Local Health District <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.. wledg and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OU1ING AND A FINAL 0 <br /> SIGNED ITLEi✓R_...� , <br /> RAW 1POT PLAN ON RE RSE SIDE) ' <br /> PHASE I <br /> OR DEPARTMENT USE ONLY <br /> � _ <br /> APPLICATION ACCEPTED BY DATE , CD �[ <br /> ADDITIONAL COMMENTS: <br /> E <br /> PHASE II GROUT INSPECTION PRASE I F. AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6 2M <br /> E H 1426 Rev. 1•-74 3/7 <br />