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-� SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> « Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pexmit,No7�- $� 0 <br /> � 1 <br /> THIS PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .' G <br /> (Complete In Triplicate) <br /> o+ the San Joaquin Local Health District for a permit to const <br /> Application is hereby made truct <br /> and/or install the work herein described. This applicstofnthe SaneJoaqu npLocaleHealthSDistrict. <br /> County Ordinance No. 1.862 and+ the Rules and Regulation <br /> t1 <br /> j JOB ADDRESS/LOCATION [//O 14:1,3 - <br /> CENSUS TRACT <br /> ' I <br /> Phone <br /> Owner's Name <br /> Gil <br /> Address 3 y <br /> License Phone <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check): NEW WELL/� DEEPEN I / RECONDITION / / DEREPLAC MEfCT ON I-7 <br /> PUMP INSTALLATION J�'I PUMP REPAIR I�I PUMP — <br /> Other / / � • <br /> . DISTANCE TO N SEPTIC TANK SEWER LINES � PIT PRIVY <br /> { SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHER <br /> P R. LINE - PRIVATE DOMESTIC WELL PUBLIC DO IC WELL <br /> G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SP ICATIONS <br /> of Well 4gsaUxatio <br /> 's Dia. of Well Casing <br /> Domestic/private \ <br /> omes c p11c <br /> Irrigation f Gravel Pack Depth of Grout Seal . <br /> RotaryType of Grout <br /> Cathodic Protection Other Information <br /> Disposal.. j Other <br /> � Surface Seal Instal ed <br /> Geophysical <br /> UMP INSTALLATION: Contractor �,]d, <br /> i <br /> Type� of Pump <br /> k M . <br /> PUMP REPLACEMENT: / / ' State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> f Approx ma a Depth <br /> DESTRUCTION OF WELL: ' -Well. Diameter <br /> Describe Material and Procedure <br /> r. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin oc 1 Health District <br /> and the State of California pertaining to or regulating we11'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin oc 1 Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well i u e. The above <br /> information is true to thelbest of my knowledge and belief. I WILL CAL R GROUT <br /> IN <br /> PRIOR TO GROUTING AND AL INSP'E IO . TITLE <br /> SIGNED t is <br /> RAW P� LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE -/&/�1-7, <br /> f APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t PHASE II IFINA INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> E H 1426 Rev. 1-7 <br />