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" SAN JOAQUIN LOC&L HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES ,I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct <br /> and/or 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 /> '1'2_&q5- 5 t Il - OIz <br /> JOB ADDRESS/LOCATION 01� OF &1,T~A__-b, oN 19PORT O P CENSUS TRACT S - S <br /> Owner's Name QAISE C� Phone $2_ DAV <br /> Address Z7 �� MCM�LLAN /�'�, City MAIJTEL'A <br /> fNC, <br /> Contractor's Name 2500 W. gU -1 RG�An License # Phone <br /> MOD€SM CAi, -- -- <br /> _TYPE -OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION/moi// PUMP REPAIR/_/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKf jg" SEWER LINES 4p o ' 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 <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - _ 01 <br /> Other Rotary Type of GroutdlZDA//TE <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / j 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 /> information is true to thg best of my knowledge and belief. <br /> SIGNED Gtr ,'� y'y' TITLE <br /> T (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE o '�47 <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTIONSE AL INSPECTION <br /> INSPECTION BY DATE - I ECTIO DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC N. <br /> E H 1426 f 4/72 1M <br />