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SAN JOAQUIN LOCAL 11EALTH DISTRICT COPY <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUI•U' PERMIT Permit No. <br /> L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-,Z1 <br /> > (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and./or ,install the work herein described. This application is made in compliance with San Joaquin <br /> r" County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> r "'JOB ADDRESS/LOCATION " ` <br /> _�, rU//_1_ _G. C� %�' `� CENSUS TRACT ` 5/ <br /> Owner's Name 11 - <br /> � F Phone <br /> r "Address <br /> t <br /> city Ay• I T1---c a <br /> Contractors Name GI f) I(I <br /> f License # %L G G2 Phone,-;If z-5 J 5�7 ` <br /> a f <br /> TYPE OF WORK (Check): hEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-] <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT <br /> +' Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS£WcR LINES PIT PRIVY <br /> SEWAGE B1SPO�IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing r <br /> Domestic/public <br /> ____ Driven Gauge of Casing + C. <br /> Irrigation � X Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> t - Other Other Information N <br /> PUMP INSTALLATION: Contractor _ ~� <br /> Type of Pump _ H.P. .vf <br /> �i PUMP. REPLACEMENT: / / State Work Dore <br /> PUMP REPAIR: / / State Work Done _ �_ 7_7�r•, 1�_ <br /> r <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—Di—strict <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 ofamy knowledge and belief. <br /> SIGNED � �/ L�, <br /> 1 / �, ice✓ TITLE 6. �-fit? <br /> (DRAW PLOT PLAN ON R 'RSE SID <br /> FOR DEPARTMENT U5E ONLY - <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> :.ADDITIONAL COMMENTS: - ice_ �" ^� t r° r r !- 1i11L,: L S'r P. i"c "r'i. <br /> PHASE II GROUT INSPECTION _PHASE I INSPE.^.T1ON'�— <br /> INSPECTION BY "� DATE INSPECTION BY '_Z� �•/, -r -,DATE `.; <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> ,a <br /> 7/72 1M. <br />