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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 W d_,� <br /> jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 14 CENSVS TRACT J <br /> 5( wner"e Name <br />. Phone:5 4 0-7 al <br /> Address. 1z(� c -� <br /> City 6-- - i <br /> Contractor's Name _ P � License ( .2}73 Phanej 3 <br /> TYPE OF WORK (Check)-. NEW WELL.'/7 DEEPENj_7 RECONDITION /J DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR-/_7 PUMP REPLACEMENT , <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE..'= PRIVATE DOMESTIC WELL`" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE.iOF WELL - `" " CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ,Tool Dia. of Well Excavation <br /> Domestic/private Dr1led Dia'.. of We' it Casing <br /> Domestic/public Dri^veri Gauge obi Caising <br /> Irrigation Gra el Pack .Depth ,o 'Grout Se '1 <br /> Cathodic Protection Rotary i T e 'of Grout, <br /> Disposal Other ...; ° 04her Iixformation <br /> Geophysical �r S fao-Sealy Installed 'By.' t <br /> / �'r � rte^•-.�.� �,�^ } <br /> F <br /> PUMP INSTALLATION:, Contractor <br /> --_ Type .of Pum? R.P. <br /> PUMP REPUCEMENT'*. — g--StaY Wbrl Done Y f <br /> A. <br /> PUMP--`REPAIRs.'�'�" " /�- State Work .Done - - - - _ - <br /> DESTRUCTION OF WELL: Well Diameterproximate Depth <br /> Describe Materlhl and Procedure . . . <br /> I hereby agree to comply with all law`s and regulations of the San Joa 'u3n Local health District <br /> And the State 'of California pertaininh-/to or regulating well `construcltion. Within FIFTEEN DAYS <br /> after completion of my work on a newael, I will furnish the San Joaquin Local Healtli,'District a <br /> WELL DRILLERS REPORT of the -well and �otify them before putting the..well in-use.... -The above <br /> information i true to the- st-of- my;t owledge and belief. I WILL CjLL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G J&D A ELM INSPECT + N. v <br />. SIGNED i TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE fir-- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , 76 <br /> ADDITIONAL' COMMENTS: r- <br /> PHASE II GROUT INSPECTION ` E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E 8 1426 Rev. 144 <br />