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"- SAN JOAQUIN LOCAL HEpALTH'�DISTRICT �7- <br /> 0 <br /> . <br /> --- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> OE OFFICE USE: <br /> Telephone: (209) 466-6781 <br /> 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> "I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `y4 l <br /> E (Complete In` Triplicate) <br /> ct <br /> Application is hereby made to.;the San Joaquin Local Health Dist date inrccompliance a permit twithnSanuJoaquini <br /> and/or install the work herein described. This ap <br /> P <br /> plication is <br /> County Ordinance No. 1862 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U Al le, CENSUS TRACT <br /> Phone <br /> Owner.'s Name ! �- <br /> L i City <br /> AddressLic� <br /> f � cense 4�� p��Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WE <br /> LL DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP REPLACEMENT T7PUMP INSTALLATION _PUMP REPAIR <br /> —Other'/ <br /> Other''/ <br /> h DISTANCE TO NEAREST: SEPTIC TANK Z&O SEWER LINES PIT PRIVY y r' <br /> � + SEWAGE DISPOSAL FIELD /0 CESSPOOL/SEEPAGE PIT OTHER ; <br /> PROPERTY LIN&Z PRIVATE DOMESTIC WELL' <br /> CONSTRUCTI C DOMESTIC <br /> O ECIFICATEONS <br /> INTENDED USE TYPE OF WELL <br /> I� Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing- <br /> Irrigation._ <br /> } Gravel Pack Depth of Grout Seal F �[ <br /> Cathodic"Protection - --Rotary Type of Grout <br /> Disposal .� Other <br /> Other Information ' <br /> Surface Seal Installed <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type ofd Pump - <br /> PUMP-REPLACEMENT: / / State Work Done .� <br /> State-WorkPDone <br /> PUMP .REPAIR: / / � + <br /> r # Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameters` <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San 7oaquin 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 we and notify them before putting the..well in use. The above <br /> information is true to the est of .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> Ot <br /> PRIOR TO GROUTING AIS AL SPE ON° TITLE <br /> r SIGNED <br /> DRp, :PL T PLAN 'ON REVERSE SIDE r <br /> } EOR DEPARTMENT USE ONLY <br /> PHASEI <br /> DATE - <br /> APPLICATION ACCEPTED B r <br /> r <br /> ADDITIONAL COMMENTS: g I/FINAL INSPECTION <br /> k PHASE II. ROUT INSPECTION B;R DATE <br /> ` j <br /> INSPECTION BY _ ` DATE .�i - INSPECTIONfes({t �w <br /> ' E H 1426 Rev. 1--74 / <br />