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SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> r O-9ZOICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ° <br /> Inio APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L�lt� <br /> 7l0--.5 <br /> THIS PERMIT EXPIRES l 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 egulations of the San Joa urn Loc 1 Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 4e=± Phone i <br /> Address City rail/ <br /> Contractor's Name License Phone -- 63� <br /> TYPE OF WORK (Check): NEW WELL '/�SEEPEN RECONDITION /_7 DESTRUCTION TT <br /> PUMP INSTLATION /7'PUMP REPAIR /� PUMP REPLACEMENT <br /> AL <br /> 4 Other /_7 <br /> f . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER`LPES PIT PRIVY <br /> SEWAGE DIS AL FIELD-CESSPOOL/ EPAGE 'PIT OTHER �- <br /> PROPERTY LINE -- PRIVATE DOMESTIC WEL UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL .CONSTRUCTION SPECIFICATIONS <br /> t Industrial Cable Tool Dia. of Well Excavation <br /> =Domestic/private Drilled Dia. of Well Casing �. <br /> f Domestic/public Driven Gauge-of Casing 2 <br /> Irrigation Gravel Pack Depth 'of Grout S L <br /> Cathodic Protectiony�totary Type`of Grout <br /> .`-Disposal Other 4 Other- Informat on .� �""'` <br /> Geophysical. SuEfMa Seal Installedr B .* <br /> •ya Lj <br /> PUMP INSTALLATION% Contractor <br /> Type of P' $ ,�.H.P. f <br /> PUMP REPLACEMENT: `/ / State Work Done .. <br /> PUMP�REPAIR: /_7 State,W' ork' Done " <br /> ES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure F ; <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 /> i fn ation is true to the my knowledge and belief.. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR ROUTING AND P . I <br /> ( ' �U <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE f } <br /> FOR DEPARTMENT USE ONLY' <br /> SE I <br /> € APPLICAT ON ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUTIINSPECTI N PHASE III N INSPECTIO .,, <br /> I INSPECTION BY DATE INSPECTION BY TE <br /> y,0v � ,�,�J 1-74 2M C <br /> / G%��"�`""" <br />