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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued�—j` f <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 Regulatio of the San, Joaquin Loc/a ealth District. <br /> ` <br /> S 0// �r o e_ � �2 � <br /> � PatJOB ADDRESS/LOCATION 1Y,. , � p6 CENSUS RT <br />, Owner's Name Phone —cico 1(0 <br /> Address Cit <br /> �` �� �� �__I � <br /> Contractor's Name /�! � PL License . Phone 6 <br /> w: <br /> t. <br /> TYPE OF WORK- (Check) : NEW WELL/�EEPEN ./ / RECONDITION /_/ DESTRUCTION /-J <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> ti <br /> DISTANCE,TO ,NEAREST: SEPTIC TANK SEWER LINESc-� PIT PRIVYyc ' <br /> SEWAGE DIS SAL FIELDkjL� CESSPOOL/SEEPAGE PIT OTHER ----- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL "'` PUBLIC DOMESTIC WELL --R <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> /,--"Domestic/private Drilled Dia. of Well Casing Pas '/ Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal p f <br /> Cathodic Protection //Rotary Type of Grout " ,/f' ,f C.0 '-C. ^� <br /> Disposal Other Other InformationZ.A-8_ �yp lY <br /> < Geophysical S rface Seal Installed B ' A, C, { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump '' H.P. <br /> PUMP REPLACEMENT,:..•• / / State: Work Done <br /> PUMP .REPAIR: / .J State Work Done <br />',DESTRUCTION OF WELL: � We11--Dia3�iieter �` -�-" Approximate Depth , <br /> Describe�Material and Procedure r` <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 before putting the..well in use.. The above <br />;inform 'on is true to the b my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A I AL I0 , <br /> SIGN t TITLE Af /Yy� SL_ • __', _ <br /> RAW PLOT PLAN ON REVERSE SIDE) j *" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br />'APPLICATION ACCEPTED BY �� DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T I SPECTIO PHASE JIT/FINAJ.7 INSPECTI N <br /> INSPECTION BY DATE / INSPECTION BY ATE �Z <br /> E H 1426 Rev. 1-74-- '-, -- - "�-> �. 2M <br />