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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -17j;~�7 <br /> (Complete In Triplicate) <br /> Applicat° oi n 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/LOCATION21�f C�j �,C r CENSUS TRACT ° <br /> Owner's Name L—U ee , / -eS Phone <br /> Address City <br /> Contractor's Name Licensed Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION - <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT // <br /> AL \1 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL a <br /> WELL <br /> INTENDED USE TYPE OF WELL CONSTRCATIONS <br /> Industrial Cable Tool Dia. of Well E <br /> Domestic/private Drilled Dia. of Well C <br /> Domestic/public Driven Gauge of Casin <br /> Irrigation Gravel Pack Depth of GroutCathodic Protection Rotary Type of GroutDisposal Other Other InformatGeophysical Surface Seal I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done ` <br /> DESTRUCTION OF WELL: WellgD a�e�ter Approximate De th <br /> tribe Material nd Procedure <br /> g �1 � is.tx4-Health <br /> I hereby agree to -ompiy with all laws and regulations the San. Joa Joaquin Local,He�a1.�h,�D' <br /> and the State of-Ca�-ifornia pertaining to or regulating we ��canstruction. Within FIFTEEN DAYS <br /> after completion of my work on a neer 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 INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> TITLE <br /> SIGNED } <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 77- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: le <br /> PHASE II GROUT INSPECTION PHASE II INAL IN PECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /4 <br /> , 1177 2M <br /> E H 1426 Rev. 1-74 <br />