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SAN JOAQUIN LOCAL HEALTH bISTRICT <br /> FOFi,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ski <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date ,Issued - <br /> (Complete In Triplicate) <br /> pplication is hereby made to the Son Joaquin Local Hoalth District for a permit to construct <br /> Wor install the work herein described. This application is made in compliance with San Joaquiv <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> A ADDRESS/LOCATION p CENSUS TRACT ' <br /> mer.'s Name /C/t�. •/ � ..+ Phone .z 3' <br /> ldress Rex R -, <br /> - 1�� City '. <br /> )ntractor's Name • " License 1 ,4A0 phone <br /> 'PE OF WORK (Check): NEW WELL DEEPEN -/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION-L PUMP REPAIR -/-7 PUMP REPLACEMENT Er <br /> Other L/ - <br /> :STANCE TO NEAREST SEPTIC TANK SEWER LINESO IT PRIVY <br /> SEWAGE DISP S&9VATE <br /> LD A�r CESSPOOL/SEEPAGE PIT OTHER <br /> j �CPROPERTY LINWBWgS IC <br /> WELL�h C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool iDia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing i., <br /> Domestic/public Driven - Gauge of Casing �} <br /> Irrigation Gravel Pack ' Depth of Grout <br /> Cathodic Protection Rotary = Type of Grout C <br /> Disposal x Other Other Information <br /> Geophysical } Surface -Seal Installed B : (, <br /> MP INSTALLATION: <br /> Type of Pump _ 4 <br /> MP REPLACEMENT: , <br /> / / State Work Done <br /> MP .REPAIR: /% State Work Done <br /> TRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local- Health District <br /> d the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> ter completion of wry work on a new well, I will furnish the San Joaquin Isocal Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting..the .vell. in.use.... .The above <br /> formation is true to`the,beet of my_ knowledge and belief. I WILL CALL FORA GROUT INS <br /> PECTI <br /> :OR �0 OUT NG AND A 29 <br /> MAL INSPECTION. <br /> GNED TITLE '' . <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY , <br /> 4SE I <br /> PLICATION ACCEPTED BY j DATE <br /> DITIONAL COMMENTS: <br /> PHASE II UT 'INSPBCTION PHASE III INAL INSPECTION <br /> 3PECTION BY DATE INSPECTION BY DATE V <br /> E H 1426 <br />