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a <br /> (7� JOAQUIN LOCAL HEALTH.DISTRIC2 <br /> FOE OFFICE'USE : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP •PERMIT Permit No. 7Z_Z,,-:�Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L� 7 <br /> t (Complete In Triplicate) <br /> Application?is hexeby 'made td the .Sau Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 an'& the Rules and Regulations oftheSan Joaquin Local Health District. <br /> JOB ADDRESS%LOCATION CENSUS TRACT <br /> Owner's 'Name i Phone <br /> Address GCI -Q City <br /> fPh " I <br /> Contractor'sl Name License # one <br /> , <br /> i <br /> TYPE OF�WORK (Check) : NEW WELL I�V DEEPEN /_7 RECONDITION /? DESTRUCTION _ . . <br /> ALL <br /> PUMP INSTATION / / PUMP REPAIR-/ / PUMP REPLACEMENT 17 <br /> a Other <br /> DISTANCE TO: NEAREST: - SEPTIC TANK (SEWER LINES PIT PRIVY <br /> ti <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 'f <br /> Domestic/private Drilled Dia. of Well Casing <br /> +a Domestic public _.._ Driven Gauge hof Casing] <br /> Irrigation - Z Gravel Pack eth -of Grout,-S-Seal <br /> Cathodic Protection , ./ Rotary Type of Grout <br /> - Disposal i Other Other Information ' <br /> Geophysical Surface Seal Installed B ' — <br /> PUMP INSTALLATION: Contractor <br /> F Type .of Pump H.P. <br /> PUMP REPLACEMENT. . / / State Work Done <br /> PUMP .REPAIR': / / "State'Work Done <br /> DESTRUCTION, OF WELL: Well Diameter Approximate Depth <br /> ! Describe Material and Procedure <br /> I hereby agkee to comply with all laws and regulations of the San Joaquin Local Health District <br /> E 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information!' is true to the-b�st of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG OUTING AND INAL I PEQTION. <br /> SIGNED 'TITLE <br /> D PIO ' PLAN 'ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ` <br /> p PHASE II gROUT INSPECTION PHAS I INAL INSPECTIO <br /> INSPECTION ,BY DATE INSPECTION BY ATE <br /> r, - ,� <br /> 1 E H:.1426 Rev. 1-74 � ( W�7� Cow, a u,�� 376' 2M <br />