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i AvSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ICVI //"'1601 - Y <br /> FOR'fOFFE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�9� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issue <br /> {Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local, Health District for a permit to construct <br /> n Joaqui <br /> and/or install the work herein described. This application is made in compliance with San <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local <br /> Health District. <br /> JOB ADDRESS/LOCATION "otop . p6 p is v e CENSUS TRACT <br /> i Owner's Name -7-1 D <br /> I Phone <br /> Address 54 i1. a <br />� City <br /> Contractor's Name License # "'Phone <br /> r <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? RECONDITION /? DESTRUCTION /-j <br /> PUMP INSTALLATION /? PUMP REPAIR , PUMP REPLACEMENT /f <br /> b DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> 3 Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 .�- OFH.P. <br /> PUMP REPLACEMENT; State Work Done <br /> PUMP .REPAIR., J9 State Work Done <br /> G �� ye <br /> ,LES. CTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 m3► 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 theibest of. m knowl a elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING ARTRA FINALE O <br /> SIGNED t <br /> TLE <br /> LOT PLAN ON SE SIDE ' <br /> PHASE I FOR DEPARTMENT USE ONLY J <br /> APP IL CATION ACCEPTED BY i <br /> ADDITIONAL COMMENTS: 'J DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE I FINAL ECTMN <br /> DATE _ INSPECTION BY DATE <br /> rvE H 1426 • Rev. 1-74 <br /> 1-74 9M <br />