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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOO OFFICE USE: 1601 R. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PBRtIT EXPIRES 1 YEAR FROM DATE `ISSUBD Date Issued T <br /> , (Complete In Triplicate) <br /> Application is hereby made to the Sea Joaquin Isocal Health District for a permit to construct <br /> and/or install the work herein described. This application is made is compliance with San Joaquri <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local health District. .. <br /> JOB ADDRESS/LOCATION q11 CENSUS TRACT <br /> Owner's Naas r Phone , <br /> AddressCit, <br /> Contractort NameLe4,ap License 4 Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/7 RECONDITION /7 DESTRUCTION /7PUMP INST"AL'�,ATION 47 PUrf REPAIR•/? Ptw REPJ.pkCEMENT /7 <br /> Other L <br />_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> PROP LINE - Pl A WgSTIC. L' P LI S TC <br /> I <br /> I SD E E OF WELL �� __ CONSTRUCTION. SPBCIPICATItyNS <br /> Indus rial Cable Took---- Dia. of Well Excavation <br /> Do�aes is/private �� Drilled � Hia=� �te11 Cid <br /> Domestic/Public Driven Gauge of. +Gaining <br /> Irri tion Gravel Pack—_ Depth of Orout 'Seal , <br /> Catho is Protection Rotary Type of Grout <br /> Die al Ott Other Information <br /> _,_,__,,,,Geoph scat Surface Se `'Installed '1 <br /> u3....^.--w. <br /> PUMP INSTAL <br /> Contractor <br /> Type of Pum - -_ . gap* <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP REPAIR 1-7 State Work Dane <br /> RES WCTION OF WELL:, WOU'7fismeter — Approxisato Depth <br /> Describe Material and Procedure ,. - <br /> I hereby agree to comply with all laws and regulations of the San .Joaquin Isocal Health Distrito <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DANT <br /> after completion of my work on a new, well, I will furnish the San Joaquin Local Health District • <br /> WELL DRILLERS REST 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. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> AP LICATION ACCEPTED BY DA 6 <br /> ADDITIONAL COMMENTS <br /> PAW12 iI GROUT INSPECTION PHASE Fes. 2NSPBCTION <br /> INSPECTION BY DATE INSPECTION BY � E -I_ t <br /> E H 1426 Rev. 1-74 2M <br />