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w r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE Og<pIM"OUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - V Telephone: (209) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT. — <br /> FROM DATE ISSUED Date Issued�71 <br /> THIS PERMIT EXPIRES 1 YEAR <br /> d <br /> (Complete In Triplicate) rmit <br /> Applicatioct <br /> n is hereby made to the San Joaquin Local HealthD istmade for <br /> compliance twith nSan uJoaquin <br /> and/or install the work herein described. This application -Is-made <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION D <br /> Phone 0 <br /> Owner's Name <br /> city <br /> Address <br /> / r s j: TwLicense # Q Phone <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check) : NEW WELL j�DEEPEN Ll RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION /✓I _f PUMP REPAIR j / PUMP REPLACEMENT 1_7 � <br /> •Other / / _ • .77 <br /> DISTANCE TO NEAREST2--SEPTIC�TANK SEWER LINES =M t PIT PRIVY <br /> Vt SEWAGE DISPOSAL FIELD � <br /> yt CESSPOOL/SEEPAGE PIT �p� OTHER (� <br /> PROPERTY LINE-—' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATION! <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domesticf /private �� � �. Drilled Dia. of Well Casing <br /> Ddm"estic/public--•--- - -Dr'iven � Gauge of Casing <br /> ( ,lrri,gationGravel Pack Depth of Grout Seal <br /> `wCathoaic Protection � Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed B <br /> .d <br /> i PUMP,. INSTALLATION: Contractor H.P. <br /> t Type of Pump g <br /> e�•`� <br /> PUMP REPLACEMENT: / / State Work Done <br /> -. PUMP=.-REPAIR: - / / State Work -Done LL " <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate' Depth V <br /> Describe Material and Procedure r <br /> I hereby agree to comply with all laws and regulationsof 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 /> t WELL RILLERS REPORT of the well and notify them before putting the well in use. The above <br /> infor on is true Co b t of-my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION_ <br /> PRIOR T OUTING AND A FI ECTIO.N. TITLE <br /> r.. w j: <br /> DRAW PI'S ' PLAN ON RE RSE SIRE ' <br /> FOR .DEPARTMENT USE ONLY <br /> PHASE I , DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CONSENTS: p II/F rAL �WSPECT'�kNEjPHA II G OUT INSPECTION ATE <br /> INSPECTION BY DATE ' 'l�3 INSPECTION BY r <br /> F , 3/76 2M <br /> ., 1. tient <br />