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i <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT ' <br /> FOE OFICEUSE: 1601 E. Hazelton Al e. ;- .S-tockton, Calif. <br /> Telephone : (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7� � <br /> THIS PERMIT EXPIRES 1 YEAR• FROM DATE ISSUED Date I' sued� � <br /> (Complete In Triplicate) <br /> Application is `hereby made to the San Joaquin Local Health District for a permit to construct f <br /> and/or .install th : work herein described. This application is made.-in compliance,Fwith San Joaquin: <br /> Count Ordinanc .- 1862 and a Rules and Regulat' ns of the S n Joaquin Local Health District. <br /> . <br /> �`r <br /> 0 DRESS A I /✓0vt / C NSUS TRACE` , <br /> e r I s ame Imo►E S CSN C P 1 `1 S-t C/M <br /> Phone ��� ��� 1/12 <br /> Address f 6X . M City \(,j 1 U L CIW D ii <br /> Co e s W T 1ta Le-� 6 U6C`7 q 4 d r License # Phone <br /> -ArCFT <br /> i <br /> 'TYPE OF WORK (Check) : NEW WELL /—/ DEEPEN ;/ J RECONDITION DESTRUCTION J? <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /% #5 Ic u R V G I pole. S ELL OI L <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Y) 1 <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> _�Geophysical Surface Seal Installed B_y: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done € <br /> PUMP .REP.AIR: / / State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> S <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 /> WELL 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 /> PRIOR TO -GROUTING D A FINAL INSPECTION. <br /> SIGNED kl&X N W C!e ft r C,r TITLE 66-ENT, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) GC0 P►i`I S i CA Lw <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 F, ; <br /> .APPLICATION ACCEPTED '$Y DATE / <br /> off <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INS�ION BY I DAT <br /> 7 yr <br /> Lel77 . 2M <br /> . EvH'r4.2$ Rev. I-74 _ , <br />