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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. '� g <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> {Complete In Triplicate) <br /> F Application is hereby made to' the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This applicati.on'is made in compli <br /> County Ordinance No. `1862 and the Rules ance with San Joaquin <br /> and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION / <br /> . CENSUS TRACT <br /> Owner'.s Name <br /> . Phone <br /> Address, 1V <br /> Contractor's Name <br /> License #/�;1� Phon+ 6 <br /> E <br /> TYPE OF WORK {Chemo); NEW WELL '/7.44 DEEPEN 17 RECONDITION <br /> PUMP INSTALLAT ON /� DESTRUCTION f j <br /> / / PUMP REPAIR � PUMP REPLACEMENT <br /> Other V_7 <br /> � 1 <br /> DISTANCE TO NEAREST: SEPTIC TANKf <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL" UBLIC DOMESTIC WELL <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONS_TR CTION SPECIFICATIONS <br /> ., Cable Tool Dia. of Well EUcavation '-- <br /> Domestic/private � Drilled <br /> Dia., of Well., .Cs1n9 <br /> Irrigation <br /> Domestic/public r Driven � u48 <br /> aig .=o£ Csin' <br /> t eb- �. <br /> .Gra�rek.Paak=----=- Grout--Sea-1-•-_. --- <br /> Cathodic Protection I Rotary Type of Grout .1 <br /> Disposal Other Other Information <br /> -Geophysical Surface Seal Installed B <br /> 2 : <br /> PUMP INSAZZATION: Contractor <br /> Type ofFui:J. j <br /> H.P. <br /> PUMP REPLACEMENT: /.] State Work Done `x <br /> PUMP :REPAIR: '. ^---��`-"----- - - <br /> -:State Work Done ' <br /> gES,TRUCTION OF WELL: Well Diameter <br /> Approximate Depth . <br /> Describe Material -and Proce lure <br /> �. <br /> I hereby agree to comply with all laws and regulatons of the San �Joaquin Local. Health District <br /> and the State of California pertaining to or regul `tfug well 'construCtion. Within FIFTEEN DAYS <br /> after completion of my work on1a new well, I will urnish the San- Toaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them b fore putting the+.well in.use... .The above <br /> information is true to the;best .of..my-knowledge an belief. I WIL . 1 <br /> PRIOR GRO TING AND FINAL' SPECT N.,_ BALL FOR A GROUT INSPECTION <br /> SIGNE .� <br /> J TITLE .fix <br /> flRAW�P PLAN ON REVERSE SID. <br /> PAS ' FOR DEPARTMENT USE ONLY <br /> AP ' <br /> PLICATION' ACCEPTED BY <br /> WDITIONAL COMMENTS i DATE <br /> PHASE II GROUT INSPECTIONfr, <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE Q <br /> � <br /> '`E $. 1426 ,Rev. 1-74 <br />