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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FdF�a:OFFS' iFSE: _ . <br /> 1601 E. Hazelton Ave., Stockton, Calif <br /> Telephone:: -- ' ��-/ �� <br /> p (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPPERMIT Permit No, E� <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued <br /> (Completelln Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for o <br /> permit <br /> and/or install the work herein described. This application is made in compliance�withnct SanuJoaquin' <br />. County Ordinance No. 1862 and the Rules and .Regulations of the San Joaquin Locel Health District. I <br /> JOB ,ADDRESS/LOCATION . ke, �- <br /> '� VENSUS� RACT <br /> Owner's Name <br /> Wt �cxs <br /> Phone , <br /> Address <br /> city . <br /> 'Contractor's Name ' <br /> License # 3Phone <br /> TYPE OF WORK (check): NEW WELL J700, <br /> DEEPEN <br /> /? RECONDITION %f DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other /_7 Y f <br /> 17 <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY- <br /> SEWAGE DISPOSAL FIELD le&t+ CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY4LINE -- PRIVATE DOMESTIC WELL" P1JBLIC DOMESTIC WELL r <br /> INTENDED USE <br /> Industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Cable Tool Dia. of Well -Excavation J a <br />_�/ Domestic/private Drilled Dia, of Well Casing r <br />____,__ Domes.tic/public _ Driver� Y =- GueJo �:ig <br /> Iirrigation Gravel Pack Depth of Grout Seal :fry <br /> Cathodic Protection -Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> PUMP INSTALLATI - <br /> ON: . Contractor - <br /> Type .of Pump <br /> PUMP REPLACEMENT / / State Work Done <br />!` MP :REPAIR: <br /> / / State Work Done - <br />)ES'TRUGTION QF WELL: Well Diameter 4 L <br /> Approximate Depth <br /> Describe' Material and.Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Loca1'Health District <br /> L"Id 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 <br /> FELL DRILLERS REPORT of the well and notify them before putting.the..well. in,use... The above <br />.nformation is true to the-bes t of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G UTING AN A NAL IN ECTIO ., <br /> IGNED r <br /> TITLE <br /> (DRA PLOT �P ON REVERSE SIDE)01 <br /> d <br />'HASE I DEPARTMENT USE ONLY <br /> P.PLIGATION ACCEPTED AY <br /> DDITIQNAL COMMENTS: f _ .. DATE <br /> 1r s _. _ ' <br /> PHAS II T NSPECT ON PHAS II INS <br /> NSPECTION BY DATE f PECTI <br /> INSPECTION BY TE - <br /> x / <br /> E <br /> H. 1426 Rev. -I-74 : :�� -- <br />