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. . •; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ILA PY: APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Z2f_27, <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,.Spn Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> Owner's Name a Phone — " <br /> Address City - <br /> JQ► <br /> Contractor's Name License Phone b <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /� DESTRUCTION-/-7 <br /> , i PUMP INS AL TION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK J "p SEWER LINE PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPO L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />`' g Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic <br /> /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 /> �b B : / <br /> PUMP INSTALLATION: Contractor U�»'� / h c lh S 7�a 1/ a�tJn•� <br /> Type of Pump MP. <br /> PUMP REPLACEMENT: / / State Work Done e <br /> I el <br /> PUMP-REPAIR: <br /> / / ..State Work Done <br /> C ( pproximate `J <br /> DES�TR.UCTION OF WELL• Well Diameter Depth S <br /> to - <br /> Describe 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 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 befog p to ting the- well in use.. The above <br /> information is true to the b t of my knowle ge an"elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG U N AND A <br /> SIGNED TITLE <br /> 41 <br /> RAW PLOT PLAN 01R)WEI. E DE <br /> FOR DEPARTME USONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �+ DATE <br /> ADDITIONAL COMMENTS: [ golp -el -! s <br /> P I RO T INSPECTI N PIEW III AL INSPECTIPM <br /> INSP.RCTION BY DATE - ._--NSPECTION BDATE <br /> E H 142 �fZ7 <br /> ,Reu. 1-74 <br />