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L- c -ice v w v/ f/ r <br />_ SAN JOAQUIN LOCAL- HEALTH DISTRICT <br />OR OFFICE USE 1601 E. Hazelton Ave.,,Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17 7-3dVtd <br />THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />(Complete In Triplicate) <br />)plication is Hereby made to the San Joaquin Local Health District for a permit to construct <br />id/or install the work herein described. This application is made in compliance with San Joaquin <br />)linty Ordinance No. 1862 and the Rules and Regulations oftpe San Joaquin Local Health.District. <br />,r <br />)B ADDRESS/LOCATION <br />mer's Name T- [ <br />idress 77�� <br />pa <br />)retractor's Name <br />M <br />CENSUS TRACT <br />0- <br /># <br /># 4� one <br />(PE OF WORK (Check): NEW WELL DEEPEN / RECONDITION /-% DESTRUCTION /-]. <br />PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT % <br />Other /: / <br />r <br />[STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DIS 0 FIELD CESSPOOL/ EP GE PIT OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />INTENDED USE <br />Industrial <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />. Geophysical <br />UMP INSTALLATION: <br />r <br />UMP REPLACEMENT: <br />74P 7REPAIR-. <br />TYPE,OF WELL <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />SPECIFI <br />Dia. of Well Excavation " <br />Dia..of Wel-1 Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />�R <br />-`/ / _State o kT�e` <br />ES4RUCTION OF WELL: Well Diameter Approximate Depth <br />Describe Material and Procedure <br />ahereby agree to comply with}all laws and regulations of the San Joaquin Local Health District <br />n'd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLS REPORT well and notify them before putting the well in use. The above <br />nformatio is true to the est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />RIOR TO G G AN A F INSPECIXION. <br />IGNED TITLE (� unua Oil/ <br />MPAW PT_nT MAN ON REVERSE SIDE) 7, <br />- FOR <br />'RASE I t <br />APPLICATION ACCEPTED BY <br />_,�;��Z4, <br />,DDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />.NS&ECTION BY DATE lvllq <br />LT•U 7/.7L h.... 7-7/. <br />ARTMENT USE ONLY <br />PHASE. 7 <br />INSPECTION BY <br />r <br />DATE 3 <br />INSP <br />