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�_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E§k FFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7 end <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7 <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 V and Regulations of the San Joaquin Local Health District. <br /> JQ <br /> JOB ADDRESS/LOCATION 2 CENSUS TRACT <br /> Owner t s Name c S2 Phone i <br /> Address ZCity <br /> Contractorts Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN '/-7 RECONDITION /_-7 ' DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7—pump REPLAC T /7 <br /> Other /-7- <br /> DISTANCE <br /> /DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic. Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump R.P. <br /> PUNK' REPLACEMENT: El- State Work Done <br /> PUMP 'REP_AIR: - J? State� ork Done - <br /> 2ES TRUCTION OF WELL: Hell Diameter Approximate Depth �►^�-fi e <br /> / _Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the 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 /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING MR A FINAL-TNSPECTION. <br /> SIGNED TITLE A�/ <br /> ` (DRAW PLOT PLAN ONEREVERSE SID <br /> FOR pEFARTMENT USE ONLY <br /> PHASE I `� <br /> APPLICATION ACCEPTED BYLI DATE Jy�{o 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P11W IX14FINAL INSP ION <br /> INSPECTION BY DATE INSPECTION BY " AT <br /> `S E H 1426 Rev. 1-74 1-74 2M <br />