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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date lss>>QcI w7 <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 , <br /> ` ��Q���raNSUs TRACT <br /> Owner's Name Phone <br /> Address / 3 --, --- -- City - <br /> Contractor's Name <br /> License Yhone� <br /> TYPE: OF WORK (Check) : NEW WELL / / DEEPEN �/�-- RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION iL�. PUMP REPAIR 1-7—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TQ NEAREST: SEPTIC TANK _____. SEWER LINES _ POO--__ PIT PR.IVY_.�.._ _ __.-_ --- r <br /> LA <br /> SEWAGE DISPOSAL FIELD _ CESSL/SEEPAGE PTT OTHER <br /> PROPERTY LINE' -� PRIVATE DOMESTIC WEI.,I: _ PUBLIC DOMESTIC: WELL _ � <br /> INTENDED USE � TYPE OIC [,JELL �� --.._____. CONSTRUCTION5_P_ECIFICA7'IONS.y. <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 _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Tnfctrmation --� _- <br /> Geophysical Surface Seal Installer_ _3 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump IIP <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material <br /> I hereby agree to comply with all_ laws and regulations of the San Jcaqui.n Local Health District <br /> and the State of California pertaining to or regulating 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 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 <br /> s1 � IT <br /> N-S'--PEPRIOR TO GRO D A FINAL L_pE <br /> SIGNED i, -Jr <br /> TITLE ilii J� N- <br /> RAW PLOT PLAN ON REVERSE SIDE) + ;reel <br /> FOR <br /> PHASE I_ ARTMENT USE ONLY P. U. Pax 201 -- <br /> --------- <br /> APPLICATION ACCEPTED BY ' Lodi, Cr1Di 4d "x:3 r <br /> 0 <br /> ADDITIONAL COMMENTS: bf <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE A— INSPECTION BY <br /> E H 1426 Rev. - I-74 DC7 i;.�77 2M <br />