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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> -Telephone: (209) 466-6781 Q / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,��/ G(! <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Loral 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. i. <br /> JOB ADDRESS/LOCATION 7.`a-Q CENSUS TRACT <br /> Owner's Name Q t Phone <br /> Address City � � <br /> Contractor's Name - -- ---- -Phone <br /> d � <br /> TYPE OF WORK (Check) : NEW WELL )Qt DEEPEN / / REC DIT ON / / STRUCTION /� I <br /> PUMP INSTALLATION / J PUMP RE A R / / P EPLACEMENT /_ <br />= Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK tOi SEWER LIMES LIZR Tir ARI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EPA E IT OTHER 3 <br /> PROPERTY LINE - PRT 0 IC WE BL C DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCO STRU TI SPECIFICATIONS <br /> Industrial Cab Too a, f elk Excavation <br /> ^ >� Domestic/private Dri1 e D a ofe11 Casing <br /> Domestic/public Driv n G u e f as ng <br /> 00 <br /> Irrigation Grav 1 ack De th of rou Seal - f <br /> Cathodic Protection Rotax Ty e f Grout <br /> Disposal Other ! 0th r Information <br /> Geophysical ur ace Seal Installed By: <br /> PUMP INSTALLATION: Cont actors ' <br /> Type Pump ; H.P. <br /> i <br /> PUMP REPLACEMENT: / 7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 ��A <br /> f the el and notify them before putting the well in use.. The above <br /> informat' i rue the es+t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GR G A I PE CT ION, <br /> SIGNED i . TITLE <br /> (DRAW PLOT PLAN ON REVERS SIDE) <br /> X, ' FOR DEPARTMENT USE OAIM <br /> PHASE I : <br /> -0 <br /> APPLICATION ACCEPTED BY�1 ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-!INSPECTION - --- -- S I3-/ IN INSPEC ON <br /> INSPECTION BY DATE �J I� ECTION BY DA , <br /> 0/77 2M <br />