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FOR OFfIC 'Ad SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION <br /> ' # OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f }} Date Issued <br /> "Application is hereby made to (Complete In <br /> Local TripliHealtcate) <br /> t nd/oraunty install the work herein described. This application Distmade inrict rcompliancea permit twithnSanuJoa u <br /> County Ordinance No. 1862 and the': Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION aQ <br /> [ Owner's Name '! �' ENSUS TRACT <br /> Phone <br /> kAddress L ` \ <br /> City <br /> kContractor'sE•Name� <br /> k t License D� Phone <br /> f <br />-TYPE OF WORK' <br /> (Check) : NEW WELL DEEPEN <br /> _I I RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> i <br /> Other <br /> / <br /> 1 - <br />(DISTANCE TO.=NEAREST: SEPTIC TANK ..� <br /> SEWER LINES: Zgp IT PRIVY <br /> iJ SEWAGE DISPOSALELD' _ p J.:- <br /> PROPERTY LINE/64 ' CECWEL SPOOL/SEEPAGE PIT �� OTHER <br /> INTENDED USE PRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL 4 # <br /> TYPE OF WELL <br /> Industrial able Tool PECIFICATIO <br /> CONSTRUCTION SNS N <br /> � <br /> Domestic/private 'r.-. Dia• of We Excavation <br /> Domestic Drilled <br /> /publicDia. of Well Casing <br /> . Driven Gauge of Casing <br /> Irrigation <br /> { Gravel Pack <br /> Cathodic Protection Depth of Grout Seal <br /> . , Rotary Type of Grout <br /> Disposal _ O'ther <br />_ ^Geophysi.-cal Other Information <br /> - Surface Seal Installed B ; <br /> PUMP INSTALLATION- Contractor <br /> --------------------- F.� Type of�Pump S r <br /> H.P. p . <br />'UMP-REPLACEMENT: e to <br /> / / Stattte Work Done <br />`UMP_.REPAIR: �� 4 <br /> State Wdrk Done I <br /> ES;TRUCTION OF WELL: Well ,Dia -ter <br /> Describe Material and Procedure Approximate Depth _ <br /> hereb"y agree to comply with. all laws and regulations of the San Joaquin Local Health Distric <br /> nd' the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> Aker completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify theca before putting the wellin use. The above <br />�IOR TO <br />-formation is true to the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> G OUTING AND.-�A�F,INA •I PECTION. ECTION <br /> CGNED 4 <br /> TITLE <br /> j (DRAW PLOT PLAN ON REVERSE SIDE) <br />[ASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> IJITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION P S I/ <br /> SPECTION BY DATE <br /> INSPECTION BFIN INSPECTION <br /> Y DATE2_, ` <br /> E H 1426 x Rev. 1-740//T /� <br /> `v r�" 1 177 nnr <br />