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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F4F�,'OFF�iCE USE: 1b01 E. Hazelton Ave. , Stockton, calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z�S <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED <br /> ' Date Issued <br /> Application is (Complete In Triplicate) <br /> hereby made toithe 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 IVo. 1862 and the Rule a and Re ulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION / <br /> 1; 7 . CENSUS TRACT , <br /> Owner's Name s — <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> - " <br /> Licensea� <br /> TYPE OF WORK (Check): NEW WELL DEEPENi ` <br /> / T RECONDITION /7 DESTRUCTION r_7 <br /> PUMP INSTALLATION /_/ _ _7 <br /> PUMP REPAIR J ./ PUMP REPLACEMENT b/ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PTT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ <br /> PROPERTY!LINE -- PRIVATE DOMESTIC WELL'-- OTHER <br /> INTENDED USE TYPE OF L PUBLIC DOMESTIC WELL Q <br /> IntEustrial CONSTRUCTION SPECIFI IONS <br />' We <br /> able Tool <br /> Domestic/privaDia.. af ll Excavation ~ <br /> Domestic/public te Drilled Dia. of Well Casing <br /> �rigation :.+ Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� 'Rotaity Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ~` Surface Seal Installed 8 : <br /> f <br /> PUMP INSALLATJON. Contractor <br /> �., <br /> Type of Pump .� <br /> _ <br /> PUMP REPLACEMENT: / / State Work Done .t y — t <br /> PUMP '.REPAIR: / / State-Work Done <br /> DESTRUCTION OF WELL Well iameter ' �1 w <br /> D b e ia1 Pro dure _ Approximate Depth <br /> _ } <br /> I hereby agree to com 1 <br /> h all laws a regulation the"San Joaquin Local Health District <br /> and the State of Cal rn a pertaining to or re ulat <br /> after completion of my work on a new well, I will furnish ethe cSan tJoaquin.Local hHeal.tin hTD trig a EEN DA � <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above 1 <br /> Lnformatio true to t est of my knowledge and belief. <br /> 'RIOR TO IN3 D A INSPECTION. I WILL FORA GROUT INSPECTION <br /> iIGNED <br /> E TITLE } <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> li �}�$ I FUR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ►DDITIONAL COMMENTS: - DATE/- I c- <br /> gt <br /> PHASE II GROUT INSPECTION rn&bE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DAZE <br /> E H 1426 Rev. 1-74^ A <br /> l t 77 � 9u <br />