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y FOSAAB ,JOAQUIN LOCAL HEALTH DISTRICT <br /> ('OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> lephone: (209) 466-6781 <br /> 7LLHISPERMIT <br /> OR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> EXPIRES REAR FROM DATE ISSUE <br /> D ��-"937 <br /> Date Issue / <br /> Applicdti (Complete In Triplicate) <br /> on is h <br /> hereby made to the San Joaquin Local Realth Districtdor za Permit to construct <br /> and/or install the work herein described. This applicatii <br /> County Ordinance Na. 1$52 and the s made in compliance with San Joaquin ' <br /> -Rules and Regulations on of the San Joaquin Local Wealth District. <br /> .TOB ADDRESS/LOCATION Q I <br /> + j, <br /> SUS TRACT <br /> Owner°s Name , <br /> Phone <br /> Address <br /> City � x <br /> Contractor w 's Name ; <br /> ' License #22/ Phone ,37�` 6 <br /> a <br /> TYP$ OF WORK {Check}; NEW WELL DEEPEN I RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTAL ./TIONPUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> .DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PfT_ 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 w <br /> � �awestic/private Drilled <br /> Dia, of Well Casi:t x <br /> " `I3`omestiC .-.._ - r g <br /> /pudic Driven"P Gauge1of-Casing4 <br /> ,Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> G thodic Protection Rotary Type of Grout _ <br /> Disposal Other <br /> Geophysical'.— -- ..� Other Information <br /> `. Surface Seal Installed B f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum_p H.P. <br /> { <br />'UMP REPLACL�MENT: // gta e Work Done <br /> P `REPAIR:.. /7 State Work Done <br /> ES;T UCTION OF WELL Well Diameter <br /> f xI , <br /> I �D Describe Material and Procedure ---- <br /> " r <br /> I hereby agree7to comply with all laws and regulations a€ the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS A <br /> after completion of my work. on a new well, I will furnish the San Joaquin Local Health District,a . <br /> WELLRILLERS REPORT of the well and notify them before <br /> information is true to the-best-of my.knowledge and belief.putting-the- well <br /> I. WILL CALL' FOR A GROUT INSPECTION sc+ <br /> sRIOR TO GROUTI AND A F NAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEP T USE ONLY <br /> APPLICATION ACCEPTED BY <br /> WDITIONAL COMMENTS: DATE <br /> PRASE II GROUT INSPECTION PHA / AL NSPECTION <br /> INSPECTION SY DATE INSPECTION BY <br /> DATE h Z_ <br /> E H 1426 <br /> Rev. 1-74 <br />