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SAN JOAQUI-N LOCAL HEALTH DISTRICT <br /> FQk OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calff. <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 Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit toonstruct <br /> and/or install the work herein described. This application is made in compliance th San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin LocalAealth District. <br /> JOB ADDRES OCATION , <br /> o� l e LENS.US Ti2ACT <br /> Owner's Name. <br /> /hone <br /> Address ` r <br /> �v 6N C- y <br /> Contractor's Name Lie ' Phone <br /> TYPE OF WORK (Check) : NE . WELL DEEPEN RE ION_ <br /> / / R <br /> PUMP INSTALLATION �lC'/ PU R�/ / DE ION /� <br /> EP EMENT / <br /> Other / <br /> PIRIVY— <br /> — <br /> DISTANCE TO NEAREST: SEPTIC T SEWER L <br /> h <br /> SEWAGE DTSP AL F ' LD E PAC P _ OTHER <br /> PROPERTY LINE .- PRI AT rIF`STIcAELL 0 STIC WELL <br /> INTENDED USE TYPE OF LL ` NSTRU ECT ICATIONS <br /> Industrial Cab l o -'ia. Well kcav on <br /> Domestic/private Drill Dia. f Well ng <br /> Domestic/public Dr'v G o C <br /> Irrigation Gra P k D h of Seal <br /> Cathodic Protection + <br /> Disposal r e o rou <br /> er her formation <br /> Geophysical ft Seal Installed B : <br /> PUMP INSTALLATION: <br /> Contract o Z <br /> Type of Pump <br /> H.P. <br /> �16 1 <br /> PUMP REPLACEMENT: / / State Wo:r <br /> PUMP ,REPAIR: a!L! �,, ✓ e G�i� �'i� 0ldsrl <br /> I / Stat Wor ne r 11 <br /> DESTRUCTION OF WELL: W ll Da ame ter <br /> �, Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to com 1 with all <br /> � y laws and regulations of the San Jo in Local Health District <br /> and the State of Cdliforni� pertaining to or regulating well construct n. Within FIFTEEN DAYS <br /> after completion.-. f my work on a new well, I will furnish the San Joaquz Local Health District a '. <br /> WELL DRILLERS 39PORT of,/the well. and notify them- before putting the well use.. The above <br /> information i true to4the best of knowled and belief. I WILL CALL F A GROUT INSPECTION <br />'RIOR TO CRO ING AN AL IjqSP <br /> SIGNED <br /> TITLE <br /> a T PLAN REVERSE SIDE) <br /> PHASE T F R DEP AR NT USE ONLY <br /> kPPLICATION ACCEPTED B DATE 6a <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ENSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 077 2M <br />