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SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED <br /> it FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. (''° ' <br /> i Telephone• 209 �.J�Cd/�� e;- f [ •/ <br /> ( } 466-6781 <br /> APPLICATION FOR WELL•CONSTRUCTTOW OR PUMP PERMIT Permit No. �p <br /> P ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued F <br /> (Complete In Triplicate) <br /> Application is hereby 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 Regulations of the San Joaquin Local Health Distrirt <br /> SWV <br /> # JOB ADDRESS/LOCATION p N <br /> CENSUS TRACT. - <br /> Owner's Name ' <br /> �G�. a Phone , <br /> Address 0 <br /> s6 c�0 City ' f. . <br /> yI <br /> Contractor's Name Ore <br /> License # Phone - <br /> TYPE OF WORK Check): �j <br /> ( NEW WELL '/-T DEEPEN/? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION J PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other /% <br /> In <br /> DISTANCE TO NEAREST: SEPTIC TANK. SE-115- <br /> S <br /> EWLI S —b PIT PRIVY ' <br /> SEWAGE DISP SA.L TELD <br /> PROPERTY LINE PRIVATESTIC WELL/�PAGE PUBLIT - OTHER <br /> INTENDED USE TYPE OF LL C DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well- Excavation - � <br /> �--p— Domestic/private Drilled Dia. of Well Casing , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel ,Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information , <br /> ..Geophysical Surface Seal Installed By-:- - <br /> PUMP <br /> PUMP INSTALLATIONo <br /> Contractor <br /> Type of Pump <br /> H.P. f \p.. <br /> PUMP REPLACEMENT: . / / State Work Donees <br /> - <br /> / <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 <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 -of my. knowledge and belief. I WILL CAI, OR AOUT INSPECTIbN <br /> PRIOR TO GROUTING-AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLAOZ��_ _Arvl,�w <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I ,Q FOR DEPARTMENT USE ONLY <br /> 1 ,0A <br /> APPLICATION ACCEPTED BY C,-.,00.r <br /> ADDITIONAL COMMENTS. DATE a <br /> PHASE II ROUT INSPECTION <br /> INSPECTION BY r PHASE TII F NAL INSPECTIONDATE INSPECTION BY DATE ti- <br /> E H 1426 Rev. 1-74 . ► ...a <br />