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CDYvi Imo, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFIfE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 3 APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. <br /> kTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i <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 a d 9 q rJri�I D�i CENSUS TRACT <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL`/? DEEPEN -/-T RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -7 PUMP REPAIR/_7PUMP REPLACEMENT f 7 <br /> { <br /> %Other / / . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 /> _2,cz_ Domestic/private Drilled Dia. of Well Casing �S <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout }� <br /> Disposal Other Other Information �o\ <br /> Geophysical Surface Seal 'Installed Bye <br /> PUMP INSTALLATION: Contractor 1_r coli <br /> Type .of Pump 16/,t, .YI.P <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP MMATR: / State Work Done,. -* Lit A104-y cd s Al <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> fafter 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 before putting the..well. in.use.... The above <br /> information is true to-the-best•of• my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR Tb GROUTING AND A FINAL IMPEC ON IL <br /> E SIGNED TITLE r Z <br /> (/ {DRAW PLOT PLAN VERSE SIDE <br /> FOR 1APARTMENT UH ONLY <br /> PHASE I <br /> APPLICATION ACCEPTA&_ .OSS EN DATE <br /> ADDITIONAL COMMENTS <br /> i PHASE II GROUT INSPECTION PEASE I F INSPECTION <br /> INSPECTION BY DATE INSPECTION BYr _- ATE <br /> i E $ w r 2M <br /> 1426 Rev. 1-74 <br />