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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> -1 JL9 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1 3 <br /> vT w�f►1 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued --'�`-`�`---f3 <br /> G-1 (Complete In Triplicate) <br /> in�d/lor <br /> ere y made to the San Joaquin Local Health District for a permit to construct <br /> install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A N/f o,r ©LTA --tLEk L! %74- ��'f%,y CENSUS TRACT <br /> Owner's Name &/i7. ,4/ ///?y A ?j LA Phone <br /> Address _ _ 2126- AL e,,nLL2W1,A1 LAN/z— city 's 7-",)C/r TON <br /> Contractor's Name L� /J /t' J I�1/ �� 1 � j �" G License �� Phone �� ! y� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /—i RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / rPUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 79C <br />_ Domestic/private Drilled Dia. of Well Casing 61 <br /> Domestic/public Driven Gauge of Casing 2 30 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 /> informationALs true to the best of my knowledge and belief. <br /> SIGNED TITLE � ,,c.�:�i° <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,p <br /> APPLICATION ACCEPTED BY 9 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY - I-7 3 DATE <br /> CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />