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SK OAQUIN LOCAL: HEALTH DISTRICT �"' <br /> S OFFICE USE: ��1601 E. Hazelton Ave..., ;Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br />� <br /> APPLICATION FOR WELL CONSTRUCTION, OR PUMP PERMIT Pera►it No.. . 6,r,�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISS ued d_ <br /> t (Complete .In Triplicate) <br /> ApplicAtj6U is Aereby made to the San Joaquin Local Health District for a permit to cpr�str14 <br /> and/or fn&tall the work ct <br /> herein described,' ' This application is made in compiiarAcg �rjth San:JAaqu*n <br />'County Ordinance No.. 1862 and the-Rules and Regulations of the San Joaquin Local:Hesith` istici�t• <br /> rr , J 3 CENSUS.TRACT. <br /> JOB ADpRESS/ .00ATION. fa' ��V <br />`Owner's Name. : Phone <br /> Cite . 44 <br /> Address. <br /> r �T <br /> Contractors Nate <br /> License #,e Phone <br /> TYPE of WORK. (Check); NEW .WELL /Yl DEEPEN-./ T RECONDZTx4N /� nES'rRUCTION; <br /> PUM.INSTALLATION L PUMP REPAIR I .l_PUMP REPLACEMENT I T <br /> 0�her� <br /> DISTANCE TO PLEAREST: SEPTIC TANK SEWER LINES PIT PRIVY. <br /> SEWAGE DiSQyS FI$LD _.. CESSPOOL/SEEPAGE PIT.. OTHER:_ ' <br /> pROPERTX LINE -- PRIVAxE DOMESTIC WELL �- PUBLIC DO STI W LL t <br /> ' INTEN—DEB 7USfiTYPE OF WELL CONSTItUCTION, S kciVICATT HS <br /> Industrial Cable Tool Dia: of Well Excavation <br /> '��" Dia. of Well Cain <br /> ., Domestic/Private Arilled S. <br /> pomsetic/publicW Driven . Gauge of Casing <br /> Ixrigation Gravel Pack Depth of Grout Seal <br /> - -- Cathodic Protection. �� Rotary Type of Grout , <br /> Disposal � Other ..Other Informatiot <br /> Geophysical ' ^�.- 'Surface Seal. Installed' B <br /> PUMP INSTAL TION:, Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Dane <br /> PUle .$$PAIR: . / /. State Work Done <br /> DESTRUCTION OP WELL: Well Diameter <br /> F7 Approximate Depth _ <br /> Describe MAftexia an ced <br /> V.I hereby��64ompj­j with all laws an re lations of fih SanJoaquin .LoFai a tb' i&t:ict . <br /> MUM- <br /> and the State of California pertaining to or. regulating well''con5truction: Within BI TEEItrlc <br /> after complet:iol of my Work on a new well., I will furnish the San Joaquin Local Health District a' <br /> WELL DRILLERS REPORT of .the well and notify then} before putting the..well in..use'.. The ,Obove <br /> inforrr�ation' is true to thebest of- My.knowledge and belief. I WILL .CALL FOR .A ROUT II�SEG: IQN <br /> PRIOR TO TINGAN NAI. INgXEcriO ITLE <br /> SIGNED' DR . <br /> . AW LOT ON R$V' SE SIDE . <br /> DERARTMENT US ONLY <br /> PHASE I DATE J: <br /> ApPLICATION. AOCEPTED BY <br /> ADDITIONAL: COMMENTS PHASE IIF IH.gEGT .N <br /> P Ih .ROT INSPECT ON <br /> INSPECTION 13Y DATE/ INSPECTION BY , SAT <br /> w -� .�C�' .. Yr:�Cif: �1✓ <br /> 1477 <br />