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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£i OFFIGE USE: 1601 E. Hazelton Ave. , Stockton,, Calif. <br /> " Telephone: (209) 466-6781 ,, <br /> APPLICATION FOR WELL CONSTRUCTION ORP_M PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued lLL�. <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit rn construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules auVRegulitions of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / ( �J CENSUS TRACT <br /> � 9� <br /> Owner's Name Phone _ <br /> ici A5--) �� <br /> Address. <br /> l �� <br /> r � � 1l License Phone <br /> 3 �� <br /> Contractors Name <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR'/ PUMP REPLACEMENT %TCk <br /> Other <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 <br /> Drilled Dia. of Well Cising <br /> F Domestic/private � <br /> Domestic/public -Driven Gauge of Casi � , <br /> ng <br /> Irrigation Gravel Pack',, :r --Depth of Grout Sea] ,x <br /> Cathodic Protection Rotary ' Type 'of-- Grout <br /> Disposal Other Other Information <br /> � , Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: • / / State Work -Done i w " <br /> w:-PUMP .REPAIR: / --State Work Don <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 i <br /> WELL DRILLERS REPORT; of the well and notify them before putting.the_well. in.use... .The above <br /> information is true 'io?.the..best .of my..knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING'--AND A FINAL INSPECTION. <br /> SIGNED TITLE - <br /> -° DRAW PLOT PLAN ON REVERSE SID <br /> FOR IDEPARTMEST USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY � DATE 1l 7 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS T,1 FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7C41 <br /> 2M <br /> E H 1426._ Rev. 1--74 <br />