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r, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> x Telephone: ( 09) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7- [� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '2 - µ77 <br /> (Complete In- Triplicate) . <br /> Application is hereby made to the Sass 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 ` CENSUS TRACT <br /> Owner's Name /7 � '�1 --- . Phone 1 3 �o �. <br /> LEa <br />' E <br /> Address - - city <br /> Contractor's NameAVI /1 a License Phone <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN '/? RECONDITION. .I DESTRUCTION /-T <br /> H. PUMP INSTALLATION /7 PUMP REPAIR-/� PUMP REPLACEMENT /7 a <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 Excavation <br /> domestic/privatey Drilled Dia. of Well Casing <br /> Domestic/public Driven --- - -Gauge of Casing _ <br /> Irrigation _ Gravel Pack— �---Depth of Grout Seal <br /> Cathodic Protection r�Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical ; Surface Seal Installed B <br /> PUMP INSTALLATION: ` Contractor <br /> Type .of Pump H.P'. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> . r ; <br /> PUMP :REP IR: / / :State Work Done <br /> ESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> - <br /> Describe Material an 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 anew 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 .af. my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTTAG A V14a INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> , ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA FIN INSPECTION <br /> INSPECTION BY DATE w INSPECTION BY. DATE <br />