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SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> EOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -71- <br /> 12=0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedDEC 28 997 <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, an s a d Regula tK, nns of he San Joaquin Local Health District. <br /> J ADDRESS/LOCATION4VCENSUS TRACT s <br /> Rp- <br /> Owner's Name <br /> fes? Phone112 € <br /> Address �� <br /> City F <br /> Contractor's Name License IV/7A Phone <br /> i <br /> TYPE OF WORK (Check)',,: . NEW WELL O DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /7 j <br /> PUMP INSTLELATION / f PUMP REPAIR / J PUMP REPLACEMENT /_7 V� <br /> Other / 7 <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER EINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY.`LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL Y1, CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool %6'011 Dia. of Well Excavation <br /> Domestic/private Drilled ti. Dia, of Well Casing 42 <br /> Domestic/public. Driven Gauge of Casing <br /> )( Irrigation Gravel Pack - , Depth of Grout Seal <br /> T'- Cathodic Protection Rotary 4 Type of Grout d_ j <br /> Disposal Other t_ _ Other Information <br /> Geophysical Surface Seal Installed By: -'/ <br /> ` } y f 1 <br /> PUMP INSTALLATION: Contractor . ' n <br /> Type of Pump ,._ H.P• <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP -.REPAIR: / / State Work Donee "` <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 'constructioh. 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 jROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> E APPLICATION ACCEPTED BY DATE '2Z,- ,7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPEECTION BY DATE <br /> h 1177 ` „ 2M <br />