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/i Ate ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE p,� ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �." Telephone: (204) 466-6781 <br /> APPLICATION FOR 14ELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-,28' <br /> (Complete In Triplicate) A <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 Rulee and Regulations of the San Joaquin Local Health District'. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> owner's Name l¢ - /-t Y Phone <br /> � <br /> Address city , <br /> Contractor' Na a. License --'Phone Y <br /> s <br /> TYPE OF WORK (Check)' NEW WELL -/� DEL�PEN '/? RECONDITION I-T DESTRUCTION 1=T <br /> PUMP INSTALLATION / / .PUMP REPAIR '/0 PUMP REPLACEMENT J T <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 /> f Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> ``1Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed .B <br /> h <br /> PUMP INSTALLATION: Contractor, I. c4 <br /> Type of Pubp -- r� H.P. <br /> 4.0f <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: �/ State Work Done 7 e <br /> M� <br /> i DES;TRUCTION 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 /> p 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 /> information is true to the-best-of y.knowledg d belief. I WILL CALL FOR A GROUT INSPECTION <br /> GPRIOR TO GROUTING -AND A FINAL IN.' 0 <br /> �3w-J�7 R <br /> SIGNED 4,+ TITLE <br /> W PLOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATA: ¢',S� <br /> APPLICATION ACCEPTED BY <br /> k ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL °INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DAT -� <br /> r 2M <br /> v n 1i.r1G nom.. 1_7L r. � <br />