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SAN JOAQUIN LOCAL HEALTH DISTRICT n <br /> Fit . OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �i t <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPI ES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Co fete In Triplicate) f <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 Ord nance. No. 1862 and; the Rifles and Regulations of the San Joaquin Local Health District.f <br /> JOB ADDRESS/LOCATION 6 CENSUS TRACT { <br /> Owner's Name ., I� U Phonefa�f <br /> Address � t._/1.C/� CitY <br /> Contractor's Name I� License # 3 / 3 -Sff 3 <br /> Phone � __� <br /> 1111 '_ 5 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ J RECONDITION J J DESTRUCTION /_7 _ Q <br /> PUMP INSTALLATION / J PUMP REPAIR PUMP REPLACEMENT / / W <br /> M — <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY41. <br /> -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ._...__ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabe oo ia. of Well Excavation <br /> Domestic/private Dr 1 Dia, of Well Casing <br /> Domestic/pub is 7& 've Gauge of Casing <br /> Irrigation r�. Pack Depth of Grout Seal ' <br /> Cathodic P o I n airy Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor. )De_, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> " ---D'escribe"Material`and Procedure ' <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 �oxk on a new well, Twill furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and no Ify them before putting- the well in use.. The above <br /> information i true to the best of my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G D A L INSPE ON. <br /> SIGNED IM TITLE .� <br /> Ip' RAW PLOT PLAN ON REVERSE SIDE) <br /> - - R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B i�. ,. DATE E <br /> ADDITIONAL COMMENTS: " <br /> PHASE 11 GROUT. INSPECTION PHASEI /FINAL INSPECTION <br /> INSPECTION BY114 <br /> Ip DATE f INSPECTION BY DATE <br /> o/I7 2M <br /> E H 1426Rev. • I-74 - = <br />