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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0r. OI'k ICE USE: <br /> /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:71-( ct) <br /> THIS PERMIT WIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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. 7.862 and the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> ,TOB ADDRESS/LOCA--ION— CENSUS TRACT <br /> Owner's Name Q Phone 592 - 31111 - <br /> Address 9� l City t <br /> ' zo9J <br /> Contractor's Name Iff At 17A �� 90� Phon � <br /> `TYPE OF WORK (Check): NEW WELL/ DEEPEN / / RECONDITION / / DESTRUCTION _1z <br /> PUMP INSTALLATION f_1 PUMP REPAIR PUMP REPLACEMENT I� <br /> .. <br /> Other ./ / <br /> N <br /> DISTANCE TO NEAREST: SEPTIC TANK 311' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS-' <br /> Industrial Cable Tool Dia. of Well Excavation 12 <br /> ^ * ✓ Domestic/private Drilled Dia. of Well Casing T � 7 { <br /> Domestic/public Driven Gauge of Casing 46 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> S. Other, _ ✓ Rotary Type of Grout Aga <br /> Other Other Informationa--_ C <br /> . i <br /> y I <br /> t .. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .? <br /> PUMP REPLACEMENT: / / State Work Done <br /> ` PUMP 'tEPAIR: / / State Work Done �x <br /> DVATRUCTION OF WELL: Well Diameter _ - Approximate Depth <br /> t 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 orf 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 /> the well and notify them before putting the well <br /> in use. The above <br /> WELL DRILLERS REPORT of e y P g <br /> information•is true to the best of my knowledge and belief.. - . - ,Q <br /> SIGNED <br /> TITLE <br /> G6f (pARW PLOT PIAN ON REV SE SIDE) <br /> - - — - �FO�PARTMENT USE ONLY <br /> PHASE I 1_�Lj <br /> APPLICATION ACCEPTED B , DATE -- <br /> ' ADDITIONAL COi-D E'.NTS: _ Y <br /> PE II_GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE 5?-/4 -7 INSPECTION BY DATE <br /> 4 <br /> - CALL- FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' <br /> 5/731M <br /> �: E H 1426 _- --. <br />