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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/U '� -7 <br /> (Complete In Triplicate) <br /> Application is he ly made to the San 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 ani the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� � �� (�- CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 7 CX City <br /> jContractor's Name r(�(�3r-ter \�,�-n��E ���"''' License '# Phone'�RLk-j-03G4 <br /> i <br /> A 1 <br /> TYPE OF WORK (Check). NEW WELL / DEEPEN/ CONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION /_ PUMP REPAIR /—/ PUMPREPLACEMENT f <br /> Other <br /> '" 3 Jf <br /> DRSTANCE TO NEAREST: SEPTIC TANK_` SEWER LINES ,PIT PRIVY , <br /> _ <br /> SEWAGE DISPOSAL FIELD �CESSPOOL/SEEPAGE PITS 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 <br /> domestic/.private Drilled . Dia: of Well Casing <br /> Domestic/public - <br /> �`� "Driven "` Gauge of Casing <br /> Irrigation Gravel Pack Depth ofd Grout ] : <br /> Cathodic Protection t Rotary '" Type.•of Grout = -/{r'�'�/� <br /> Disposal ...— <br /> Other '; Other Iniformation <br /> Geo h sical Surface SealfInstalleF <br /> d`By• `J <br /> PUMPINSTALLATION'e` "*Contrart`orT - - <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: /. / `State•Work Done ' 4 e <br /> PUMP .REPAIR: / / 'State Work Done <br /> DESTRUCTION OF WELL: Well ,Diameter Approximate Depihi -3_. <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 workyon a new 5well, I will furnish the San IJoaquin Local•Health District a <br /> WELL DRILLERS REPORT of-the�well`aud notify them before putting the .well`in •use. The above <br /> infor tion is true tot f knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO ROUTING ANDA N S ON- <br /> SIGNED <br /> NSIGNED TITLE, 2,Q) 6 U ` <br /> F RAW I'i:'T PLAN 'ON REV'EItSE SIDE) '~ <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE 4��y�, , <br /> APPLICATION ACCEPTED BY `�`�'v PATE <br /> ADDITIONAL COMMENTS: <br /> PHA I GRO T INSPECTIONj r' P S I I/FIN INSPECTION <br /> INSPECTION BY DATE t, _ 7? INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 3/�76 2M <br /> �.d�r <br />