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•a'! I� PLOT l i.. N <br /> (DRAW TO SCALA:) <br /> SCALE " TO <br /> •-2 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r'OR OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (^09) 4f6-6181 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT o. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is liereby 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 Rule and Re ul tions of the San. Joaquin Local Health Dietrict. <br /> JOB PDDRESS/LOCATIO 140 f d rT O ENSUS TRACT <br /> Owiter's Name !` a �° Phone <br /> Address d'a' V0f City <br /> �s Contractor's Name 4 'J�2yt� 1 License 0a27hone <br /> Y� k <br /> 5 TYPE OF WORK (Check): NEW WELL f DEEPEN /7 RECONDITIO /7 DESTRUCTION-fT �r <br /> Y PUMP INS LATION / / PUMP REPAIR 1-7—Pump REPLACEMENT /7 <br /> Other <br /> r <br /> } ISTANCE TO NEAREST: SFPTIC TANK SEWER LINES IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS DOL/SEEPAGE PI OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ._.,, PUBLIC DOMESTIC WELI�...,� � f" <br /> INTENDED USE TYPE OF WF.LL CONSTRUCTION SPECIFICATIONS r' <br /> nr Industrialle Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ^ <br /> Domestic/public Driven Gauge of Casing <br /> _,,b, I rrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> a Disposal Other Other Information �— <br /> :,t Geophysical Surface Seal Installed By. <br /> h. i ...ii�.•ii. ii.�i Err <br /> PUMP INSTALLATION: Contractor <br /> fj Type of rti.mp _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done ...,.,.. <br /> PUMP .REPAIR: / / State Work Done <br /> .e <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> a <br /> r� Describe Material and Procedure <br /> t; <br /> i 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 DAIS <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 my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GROW Nd D A 'INAr, fi 1- �ION.lk <br /> SIGNED / TITLE <br /> DRAW PL9T PLAN ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE? INSPECTION BY DATE .o-../_..� <br /> '. F. <br /> 11 1426 Rev. 1-74 � 1177 'lM <br />