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lv AI- TOAQUIN LOCAL HEALTH DISTRICT y <br /> .06 OFFICE USE: 1601 n.: Hazelton Ave. , Stockton, Cali <br /> p Telephone: (209) 466-6781 u <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP Pt T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ?plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> jd/or install the work herein described. This application is made in compliance with San Joaquin <br /> aunty Ordinance No. 1862 and the <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION /fes �v �S'bza� CENSUS <br /> TRACT <br /> wner's Name � Phone <?/ " <br /> 1dress /1Itv City . <br /> ontractor's Navel' ) � PQJA4/ 5 License 1/0 <br /> � <br /> -7 hone 9r <br /> YFE OF WORK (Check) : NEW WELL. Af DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION I)q PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEP PIT OTHER <br /> PROPERTY LIN RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing b <br /> Irrigation s/ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ✓ Rotary Type of Grout �7 <br /> Disposal Other Other Information f�'l/ ' ✓� <br /> Geophysical Surface Seal Installed By: <br /> �) <br /> '?SP INSTALLATION: Contractor 'C/� �G/L�P'S <br /> Type of Pump >NR� U /aH.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> vESTRUCTION 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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO G UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> DEP MENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEP B SNAVL� DATE Z ZZ 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE / INSPECTIO1N BY. DATE <br /> s3/ .� /dlF �O Ll te� �OZ r e ��• � 'r'i1 Lirt I �6 2K <br /> E H 1426 Rev. 1-74-)„< )r..,4yiJ i'�ci`f <br />