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,. <br /> r1AP <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i'FOR OFFICE USE: 1601 E. Hazelton Ave.,, `Stockton, Calif. <br /> Telephone: (' (209.)..466=6781 <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'-72- <br /> it <br /> o.'72-'s <br /> I _. . . . � c.' t <br /> THIS `PERMIT EXPIRES' 1 �1'�EAR�rFROM"DATE ISSUED- D"ate Issued` j.S: 7 L"i ; <br /> •;;�!� .!. .i.3L.t ,_! .gip-��zsa� cs•;�:�.,.�i.yx(Complete In Triplicate)' , <br /> , Application is hereby made to the San Joaqufi0t`ocalllHealth'�bistrict for a permit to construct <br /> ,,. t <br /> , and/or,install'•tii�e�°i�ork.� h'exe .n`�d'ersc'ribefd.``;"This ap�ilcation°is:made-''in- compliance with San'Joaquip <br /> County 0 dinan`ce N6-:'`1'8F62--'and the` Rdl`es;Eind`'Regulctioiish'bf the `'San Joaquin Local Health Di"strict. :2 <br /> JOB ADDitESS/LOCATION a S/ fiE �I� L KG�I "f ;mss a` CtNSUS 'TRACT �.. "; <br /> !i') <br /> I�, r <br /> Owner's!Name 3',4 ..�I/y .`S� �Dl�ii' �i� - - Phone " q <br /> Address' . ���5. ' i /�f CIS G i��iFp� 615 '1F ly C-14M 7 City <br /> Contractor's Name �',� /P C G, License # LG2z Phone r - <br /> iI <br /> TYPE OF WORK (Check) : . NEW WELL / / . DEEPEN:/ / RECONDITION /� DESTRUCTION I-T <br /> u iPUMP INSTALLATION :/ / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> i Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ' TYPE' OF WELL - z o r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ;of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal Q 1 ' <br /> Other ✓Rotary Type of Grout y <br /> Other Other Information <br /> PUMP INSTALLATION: ;; Contractor ,. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: !-- / / State Work Done <br /> PUMP REPAIR: rY ' / / State Work Done <br /> ,DESTRUCTION OF WELL:` 'Well D' 'me t ' Approximate Depth <br /> ' y p Describe Material andProcedurei <br /> ! I hereby agree to'comply with all 1Aws 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- myjwork 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 /> informati.6n is true to4the best of'my `know;ledge and belief. <br /> y TITLE �rl�Ll --...5IGNED , � , . _ �- _ - __ 7-- <br /> (DRAW <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> -FOR IIEPARTMENT USE ONLY <br /> • PHASE I { E <br /> APPLICATION ACCEPTED BY f` = DATE77 Z <br /> ADDITIONA, COMMENTS: u , <br /> PHASE 11 GROUT INSPECTION PHAVt-TIIjFINAjLe INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 14'26 4 72 1M C <br />