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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .. <br /> FOR OFFICE Ave. , Stockton; Calif <br /> USE: 1607. E. Hazelton <br /> Telephone: (209) 466--67$1 (, O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> °l q 4 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10 71, r. <br /> (Complete In Triplicate) <br /> Application-16 hereby,'.made"tio the"San Joaquiri'Local Health District fcir a`permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No'. 1862-andtthe Rules and-Regulations"of 'the San Joaquin Local Health District. A <br /> So,-"CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION, ` , <br /> Phone 6 Li, <br /> Owner's- Name.. - <br /> • city S <br /> Address . <br /> Contractor's Name T GGD!$ S c ! -License # lzffr04 Phone ' o X <br /> a <br /> TYPE OF WORK (Check) : RNEW WELL .�',� DEEPEN /7 kECONDITION. /' / , .bESTRUCTION F. _ <br /> -� s- PUMP IN5'TALI,ATION ./ / PUME' REPAIR`// / PUMP REPLACEMENT /? <br /> Other../ / <br /> DISTANCE TO NEAREST: TANK/OLD'— SEWER LINES _- PIT PRIVY j <br /> SEWAGE�DISPOSAL_FIELD..-. CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> — Cable Tool �. Dia. of Well Excavation <br /> Industrial _ a <br /> Dino of Well Casing <br /> Doi►es.tic/private. Drilled Gau a of Casing , Z - <br /> Domestic/public � Driven` g <br /> - - Gravel Pack Depth-of.Grout-Seal._ -ro`' <br /> Irrigation <br /> Other t Rotary Type of Grout G ` <br /> i Other Other Information ' <br /> LG -761 . <br /> PUMP INSTALLATION: Contractor , _ P H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / -State Work Done <br /> PUMP REPAIR• / / State Work Done <br /> . <br /> i pE5TRUCTION OFWELL_: Well,Diameter <br /> Approximate Depth ` <br /> t 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 pand belief.- <br /> SIGNED -'t � TITLE <br /> ( W OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHAS II GROUT INSPECTION INSPECTION BY �/� DATE <br /> INSPECTION BY _ DATE : 7 -/G-7 - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M . <br /> E H 3.426 <br />