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F08rOFFIC$ USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit no. 7Z. <br /> THIS LX.RMT 8XR'IRES 1 YZAR MMDATE ISSUED Date Issued2. .:�7 <br /> (�D <br /> (Complete In Triplicate) <br /> Application is hereby as" to the San Joaquin Local Health District: or a permit' to construct <br /> and/or install the work herein described. This application is made to compliance with son Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION CENSUS TRACT <br /> Owner's Name Phone �9 <br /> Address City <br /> Contractor's Nam LicensePhone -YL? J <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION 0 <br /> PUMP INSTALLATION L-7_PMREPAIR 1_7 Pt1MP <br /> Other L7 <br /> ST/►NCE TO NZAREST: SEpTjj4 TANK Son Lau PIT POVY <br /> SEWAM DISPOSAL FIELD CESS 0/SEEPAGE Pxy ' OTH <br /> P - P V : SIC PUB ,I S <br /> INTENDED USE TYPE OF UCTION �PECIFI <br /> Industrial Is 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 S <br /> Cathodic Protection Rotary Type of Grout <br /> ____,_Disposal Other ��� Other Information_ <br /> Geophysical <br /> Surfffa SurfSem I**&LW4 Bvt <br /> PUMP INSTALLATION: Contractor <br /> Type of Bp 8 _...__....... <br /> PUMP REPLACOXINT: L7 State Work Done <br /> I'�1MP 1112PAIR: i <br /> L7 $tom Work Dams-.—i <br /> TRUCT�IONOF WELL: Well Diameter Approximate Depth <br /> Describe-%'-serial and Procedure <br /> I hereby agree to comply with an lsws and regulations of the San Joaquin Local HiialthDiatric <br /> and the State of California pertaining to or regulating well construction. Within FIFTH DA'f <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in use.. The abo9e <br /> information is true to tote•best of my knowledge and belief. I WILL CALL FOR A'GROUT INftMCT <br /> PRIOR TOG UTI AND INAL > S ION, <br /> SIGNED TITLE <br /> DRAW PLOT PLAN .OF 8 SIDE <br /> DZPARTMM <br /> R IISE,ONLY <br /> PHASE I <br /> APSCATION ACCEPTED BY DATA <br /> ADDITIONAL COM1O NTS <br /> 44 <br /> PHASE iI GROUT INSPECTION RASE 11171W INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ti' - -7 <br /> E H 1426 . Rev. 1-74 -1_74 2M <br />