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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 _ q �4e_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM T Permit No. 7P <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED. Date Issued '7f <br /> (Complete In Triplicate) <br /> Application is hereby 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 Joaquir <br /> County Ordinance No., 1862 and the Rules and Regulations of the San Joaquin .Local Health District. <br /> �2,� �,�G✓/i✓ �f7` <br /> JOB ADDRESS/LOCATION .;,�iv .. Af- 'i �s �- �/ 'I) i�r11 ENSU TRAM <br /> Owner's Name DS A R - Phone <br /> f <br /> Address j'�►S - `Q t �>r► ,q: City c � <br /> License # ( PhoneContractor's Name 2 � ��%�fJf✓ '�, �so%� �`� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMPIINSTALLATION / ;/ PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other /% .h -9 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -. <br /> SEWAGE DISPOSAL FIELD � .CESSPOOL/SEEPAGE PIT _ OTHER C <br /> PROPERTY LINE - PRIVATE DOMESTIC'WELL .""" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> IndustrialCable Tool Dia, of Well. Excavation <br /> Domestic./private = t T-Drilled Dia, of Well- Casing <br /> Domestic/public Driven Gauge of Casing w <br /> ""I`rrigation •"""�""''"`-gavel Pack Depth of GroulneaL ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface -Seal Installed B, <br /> PUMP INSTALLATION: Contractor _ ' t•. _ <br /> Type' of Pump <br /> y, t. <br /> r ° [ <br /> PUMP REPLACEMENT: / / SState Work Done <br /> PUMP''REPAIR: St•a'te Work Done <br /> Ie <br /> DESTRUCTION OF WELL: Welf Diameter Approximate Depth M T <br /> .,Describe Material and Procedure <br /> f ' <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, 1 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 tb the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND .A NATje INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR 'DEPARTMENT USE ONLY <br /> PHASE I ��` . - <br /> APPLICATION ACCEPTED BY DATE •—/S'- <br /> '` ADDITIONAL COMMENTS: I , A0 - <br /> PHASE II GROUT INSPECTION P PHASE I;WFIN4 INSPECTION L <br /> INSPECTION BY .1 DATE INSPECTION BY DAT <br /> 2M <br /> E H 1426 Rev. . 1-74 <br />