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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:. <br /> ; .r r. <br /> 1601 E. Hazelton Ave. , Stockton, CaIiF.' <br /> Telephone: (209) 466+-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No73-3 9 s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued/G 73 <br /> GCS( S CA � (Complete In Triplicate) <br /> , Application is here to t e an ma a Joaquin Local Health District for a permit to construct <br /> and/or install therk herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> M.1� w'/sy 1)21,iG �cv2Rn � /tori. vw fm�Di� 7`t7gGy � <br /> JOB ADDRESS/LOCATION COa4,1./fv449�•6w tf-0-1! CENSUS TRACT ' <br /> Owner's Name Gt}2/;�L �yLLpw Su��i ✓ VO ./JO nl GvS P3 5— �?( <br /> Phone 3 6 e ' <br /> Address /�C s c. dZ '?'��C. <br /> ✓ � n � � Y City , T-rt,1_4.Y <br /> Contractor`s Name S 3/9NfSISS License #/793M(- Phone <br />—TYPE OF:W©RK (Check) ., NEW WELL DEEPEN '/—/ RECONDITION /_� DESTRUCTION /_7 � <br /> PUMP INSTALLATION PUMP. REPAIR / / PUMP REPLACEMENT /- <br /> 4 <br /> Other <br /> w4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Cry°I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled- Dia. of Well Casing / k <br /> �✓ Domes tic/public Driven Gauge of Casing <br /> Irrigation �G Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ' . <br /> Other Other Information =.6 <br /> PUMP INSTALLATION: Contractori�Y -�SLs V-,-i 0 <br /> Type of Pump fn.O(7 T7f�ni�;y.,•.. L.„V2 01 r. f H.P. <br /> PUMP REPLACEMENT: i-7 State Work Done <br /> PUMP REPAIR: /7 State Work Done s <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 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 /> 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. <br /> SIGNED TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I } f <br /> APPLICATION ACCEPTED BY DATE 1bI �3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INP ION. <br /> E H 1426 4/72 1M <br />