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SAN JOA <br /> Q HEALTH DISTRICT <br /> FOR,O T1;E USE: 1601 UIN LOCAL E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 /px1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1p S <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 Health District. <br /> JOB ADDRESS/LOCATION3 1.G Yvf� CENSUS TRACT <br /> Owner's Name onx Phone <br /> Address emp 9ani[! <br /> City ' ' <br /> Contractor's Name License one L • <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/? RECONDITION %f DESTRUCTION _�f <br /> PUMP INSTALLATION �/ PUMP REPAIR '/� PUMp REPLACEMENT <br /> Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Cable Tool Dia. of Well Excavation4 <br /> _ Domestic/private _ Drilled Dia. of Well Casing (A <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 INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT X1 State Work Done? / <br /> PUMP +REPAIR: %/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 before putting- the-well- in-use... The above <br /> information is true to the•best .of my..knowle a nd bel' f. I WILL CALL A GROUT INSPECTION <br /> PRIQR TO NG AND A PIN SPECT , <br /> SIGNED <br /> MAR OF DRAW P QN REVER E IDE <br /> PHASE T <br /> DEPARTMENT USE ONLY <br /> APP IL CATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPLfCTION PHASE III FINAL INSPECTION , <br /> INSPECTION BY _ - DATE INSPECTION BY �'1 .. DATE /j ,,;s j � <br /> - E H 1426 Rev. 1-74 <br />