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_ _ _. ... —awa•hw�.atr..ir ra ew iiiiresr_ w�.r� ,w x,.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FWeOFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -5-7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun 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/LOCATIONQ,- CENSUS TRACT <br /> Owner's Name Phone , <br /> ,Address <br /> pity . . <br /> Contractor's Name � � License # I'3 x —Phone <br /> TYPE OF WORK (Check) ; NEW WELL /'7 DEEPEN /7 RECONDITION 1? DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/_7 PUMP REPLACEMENT 17 <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 CONSTRUCT TON SPECIFICATIONS � t <br /> Industria] Cable Tool Dia. of Well Excavation <br /> ✓Domestic/private Drilled Dia. of Well Casing L� <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack, Depth, of Grout Seal � I <br /> Cathodic Protection Rotary 'Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical ~- Surface Seal Installed B <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT State Work Done <br /> PUMP .210AIR: 22T State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> 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 ofknowledge Mad belief <br /> PRIOR TO R . TWILL GALL FORA GROUT INSPECTION i <br /> UTTNG D A VTknowledge— <br /> SP I <br /> STGNE c4.- d <br /> TLE <br /> ( PLOT PLAN ON FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ZA DATE <br /> PHASE II GROUT INsP9cTIoN <br /> INSPECTION BYP E TII . INAL INSPECTION <br /> DATE INSPECTION BY DATE <br /> ti E 19 1426 Rev. 1-74 s �...� ..._ <br />