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}) JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OF ICE USR: ' ' 60En. Hazelton Ave. , Stockton, Calif. .. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1.2 y-3JQ <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 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 /> CENSUS TRACT ' <br />.JOB ADDRESS/LOCATION & / <br /> Owner`s Name Phone + J O <br /> Address 'L City <br /> Li <br /> Contractor s Name <br /> h <br /> ,� cense # e <br /> ., <br /> IL <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/ /� RECONDITION /-7 DESTRUCTION /-7 t r <br /> PUMP INSTALLAT <br /> Til iION / s PAIR ' , P REP AC NT <br /> t4se's QCs dF �+`d I •` � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES PIT PRI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE A PIT OTHER <br /> PROPERTY LINE -- PRIVATE 'DOMESTIC WELL PIVLI MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONS CAMN 'SPECIFICATIONS <br /> Industrial Cable Tool ' Dia'. A Well ca ti n <br /> Domestic/private Drilled D'a. Well Ca i g <br /> Domestic/public Driven uge o Casing <br /> Irrigation Gravel Pack pth f' rout Sea <br /> _ Cathodic Protection Rotary p o GroutI <br /> Disposal Other O hInformation <br /> Geophysical face Seal Ins a B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Wo k <br /> PUMP .REPAIR: State o <br /> DESTRUCTION OF WELL: Well Diameter s Approximate Depth <br /> Describe Material and Procedure <br /> Thereby agree to comply with all laws and regulations of1the San Joaquin 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 /> f information is true to the best of my-k owled epalid� elief. I WILL CALL FOR A GROUT INSPECTION <br /> ` PRIOR TO UTING D A FIN C ON. , <br /> SIGNED :. ITLE <br /> D T -r AN ON R RSE SIDE) <br /> F FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> � DATE � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> f PHASE II G' N RECTION PHA AL INSPECTION <br /> k 41 <br /> INSPECTION BY DAT�yEy� /y NSPECTION BY DATE�IZ _ =Tryp�_ <br /> r E H 1426 Rev: 4 !! C/ <br />