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--F-09--OFFICE USE: AV, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " 160WELL CONSTRUCTION OR PUMP PERMIT Permit No.E. Hazelton Ave. , Stockton, Calif. /�/��1 L r0 60An R <br /> ION <br /> l3 Telephone : (209) 466-6781 <br /> APPLI CAT 0 FOR WE �'3�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z ] <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/LOCATION fCENSUS TRACT <br /> Owner's Name �� Phone <br /> Addressliz City <br /> Contractors Name ' License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> Cj <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -J <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 /> Domestic/private Drilled -Dta.:' of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection VRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <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 /> 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �-7 <br /> APPLICATION ACCEPTED BY DATE Z1 / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE IINNjS�PECTION BYDATE 3-2P-7� <br /> E H 1426 Rev. - 1-74 <br />