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_ SAN JOAQUIN LOCAL.-HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel.tonnAve. , Stockton Calif, <br /> Telephone: .;.. (209) '466-6781 <br /> 4 "Al owl <br /> APPLICATION FOR WELL CONSTRUCTION.OR PUMP PERMIT Permit No. 72_ 6L5 <br /> THIS PERMIT,EXPIRES;l iYEAR':FROM.':.DATE ISSUED', " Da'te Issued 6-.2_C: 72_-- <br /> (Complete' <br /> -.2_C: 7Z..(Complete inTriplicate) <br /> Application,.is .hereb:y-;made -to theT Sane Joaquin..�Loca1 Health District for -a,permit'to• construct <br /> and/or insta111the work herein described. Th siapp.lica:t on'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 5/ 7� ALP VV V r 'CENSUS TRACT <br /> Ci <br /> Owners Name'.}1 /1 W c `N i t E+ h-J111 E , La ._ , Phone <br /> Address L,I.L1�Lj 1Y H A11, Ci.ty. . 57a aAk,,T. J_. <br /> Contractor's NamePhone '.. License � ��. <br /> ..fkk6- 7J 70 <br /> 6,410 o E <br /> TYPE OF WORK (Check) : NEW WELLAI DEEPEN-/% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION j / PUMP REPAIR J / 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 f <br /> Industrial" X Cable :Tool Dia. of Well Excavation ,J <br /> Domestic/private Drilled Dia. of Well Casing I D`' A,j H U/C I L <br /> Domestic/public Driven Gauge of Casing , o G/} <br /> X . <br /> { <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 /> i <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 610ti4 <br /> PLOT PLAN ON REVERSE SIDE) <br /> /"F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE !?✓" <br /> ADDITIONAL COMMENTS �i-GZZ <br /> PHASE II S C N PHA NAL IN PECTIO <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT ,INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 4/72 1M <br /> j <br />