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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. <br /> THIS. PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED Date Issued <br /> t (Complete In Triplicate) <br /> Application is hereby made to,Ithe 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 andIthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 142S,7/ I fG� Pi <nciM CENSUS TRACT <br /> Owner's Name r Phone 2— 1, <br /> Address 3 City <br /> Q �� <br /> s - <br /> Contractor's Name LLA R. I�Qj t f L7 (3U)PNr�v �--. License #7�10 Z Phone zAt Z ?'I <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES, _ PIT PRIVY j - <br /> SEWAGE DISPOSAL FIELD ;.CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE',DOMESTIC WEI S`-' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial J. , Cab-le Tool Dia, of Well Excavation <br /> �'Daiuestic/private `'` Drilled Dia, of Well Casing <br /> Domestic/public Driven ;' Gauge of Casing G <br /> Irrigation "` ' 'i -Grave-i/Pack Depth of Grout Seal Cb <br /> Cathodic Protection `_ atar/y Type of Grout _� � <br /> Disposal ,i, ..-Other Other Information �. <br /> Geophysical F ' � Surface Seal Installed By: <br /> j- <br /> PUMP INSTALLATION: Contractor <br /> Type ,o£,P.u&p- � :. � H.P. ' E <br /> PUMP REPLACEMENT:- / / State Work Donee <br /> PUMP .REPAIR: %/*{State Work Done _ <br />' DES-TRUCTION OF WELL: 'Well Diame-ter` r_t Approximate Depth <br /> Describe Matrial '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 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�be.fo e. putting.:.:the`"well in use. The above <br /> information is rue to the best of my knowledge and rbeli:ef: • I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UT NG D A WN TIO 'A1 <br /> ik SIGNED �, _ _ ' _ TITLE W1Ar <br />! (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> 4 APPLICATION ACCEPTED BY- � DATE <br /> ADDITIONAL COMMENTS=. , <br /> PHASE II OW/INOECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY /` DATE /& 3 - 7 INSPECTION BY DATE ., d -3-7] -- <br />�° E H'1426 Rev. . 1-74 <br />