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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USEc 1.601 E. Hazelton Ave. , Stockton, Calif. -` <br /> Telephone: (209) 466-6781 p <br /> AP ;�;ICATION FOR WELI.,COiVSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED' , Date Issued Y2K <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 Rules and Regulations of the San Joaquin Local Healthistrict. <br /> r <br /> JOB ADDRESS/LOCATION /I�-A /�/QSSQ'YJ O ([J7• CENSUS 'TRACT <br /> Owner's Name � � Phone <br /> Address � r City <br /> Contractor's Name � License # 4­' Zjjhone <br /> r , <br /> 4 i <br /> TYPE OF�tWORK .(Check) NEW WELL DEEPEN,;/7-/-,. RECaNDITTON:/?, DESTRUCTION,f�T <br /> s9 —PUMP�INS -L�1T30N /—PUMP,.REPAIR f / PUMP-REPLACEMENT-- <br /> .DISTANCE <br /> REPLACEMENT.DISTANCE TO i NP_kREST: SEPTIC TANK ""`'SEWER--i:INES� PIT PRIVY_ <br /> N - <br /> { - SEWAGE DISPOS FIELD -fes CESSPOOL/SEEPAGE PIS OTHER ` <br /> PROPERTY LINE - PRIVATE'DOME"STIC WELL'-==-- PUBLIC DOMESTIC WELL ;H= <br /> INTEN-]ED2$9 TYPE OF ;WELL__'- CONSTRUCTION SPECIFICATIONS <br /> Indus�riaZ��'4., Cable Tool -4:i Dia. .;of Well Excavation � � <br /> DomesDrilled Dia. of Well Casing <br /> Domestic/pu-1ic Driven Gauge of 'Casing ej?zz zi ye; 6-rag <br /> Irrigation <br /> :,, Gravel Pack �;, -Depth of Grout Seal f f <br /> Aathodic Protection Rotary Type .:of Grout <br /> Disposal Other: �'. Other'Information <br /> Geo,physical Sur <br /> - face Seal Installed 'B E� H <br /> PUMP INSTALLATION: Contractor <br /> } vTYp4 of Pump H.P. <br /> PUMP REPLACEMENT: State Work <br /> Donep / �D <br /> PUMP .REPAIR:_ <br /> j / State Work-.Done -" / .� • <br /> DESTRUCT ...01k � WELL: Well Diameter., � Approximate Depth' <br /> Describe•Materia? and Procedufe ,_ +- <br /> I hereby .agree to comply with all laws},and regulations of the San..Joaquin Local Health District <br /> and:,.the State of 'California pertaining to or regulating well'-construction. Within FIFTEEN `DAYS <br /> after cot et'i my' work .on a new well, .I will furnish the- SAii-Joaquin Local Health District a <br /> WELL DRILLER REPORT' o the' well d notify m before putting the..well in use The above <br /> information is t ue he b st o e e and belief. I WILY CALL FOR GROUT INSPECTION <br /> PRIOR-TO G UT FI IN :'` <br /> SIGNED TITLE <br /> D W P ON MSE SIDE. r ; <br /> - <br /> _., -FOR"DEP- MENT`USE ONLY - - -. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_ —'� <br /> ADDITIONAL- COMMEr1TS: zZ - <br /> `" IiAS$ I OUT INSPECTION PHASE III/FINAL INSPECTION <br /> 5 <br /> INSPECTION BY DATE ! , INSPECTION,.BY= DATE 7. <br /> E H 142b ��' 76 .. <br /> Rev. 1-74 <br />