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Ile <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ,, Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date- Issued , 5- <br /> (Complete <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r; <br /> JOB ADDRESS/LOCATION c O (- Z , •CENSUS TRACT - <br /> Owner's Name 3 GLC Tp Phone <br /> Address 1_7' / p -City S 7kzy <br /> i <br /> Contractor's Name /�j 7i License �� 2S'/D PY,one <br /> II <br /> �I• <br /> TYPE OF WORK (Check): NEW WELL & DEEPEN -7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT .i /? <br /> Other / j i <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ---�.- it <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial Cable Tool Dia. of Well Excav - <br /> X Domestic/private Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casino /2 .ii _ 11Q <br /> Irrigation Gravel Pack Depth of Grow al S`e 1i 14 <br /> Other Rotary Type of Gr�pu <br /> Other Other f9 matipn - c• liA- — <br /> C <br /> PUMP INSTALLATION: Contractor r �! <br /> Type of Pump cc. H.P, z <br /> r 1 . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION _OFWELL; Well Diameter s Approximate `Depth <br /> ' T Describe Material and Proc dure �! <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 ,cell, 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.1 The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE �•-�� <br /> DRAW. PLO LAN ON REVERSE SIDE <br /> FOR - PARTMENT USE ONLY <br /> PHASE I.- <br /> APPLICATION ACCEPTED B/-..-'Ol <br /> DATE �•rj <br /> ' ADDITIONAL COMMENTS: gy <br /> PHASE II GROUT INSPECTIONPHA I INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -z - . 3 <br /> CALL FOR A GROUT INSPECTION PRIOR...TO GROUTING AND FINAL INS <br /> E H 1426 7/72 IM <br />