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SAN JOAQUIN LOCAL HEALTH DISTRICT OCL /CU r� <br /> FOR OFFICE USE- 1601 E. Hazelton-Ave. , 'Stockton, Calif. <br /> 1."/ <br /> Telephone: .. (2G9)-.,46k-6781 `]5 2 <br /> APPLICATION FOR WELL CONSTRUCTION-•OR PUMP PERMIT Permit No. 7 -1111,p <br /> THIS PERMIT.,EXPIRES l.-YEAR-,FROM DATE ISSUED Date Issued <br /> k: (Complete In-Triplicate) '�J <br /> Application is hereby:.ma.de 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 /> County .Ordinance No.�. 1862 ,and the -Rules' and Regulations -of •the .Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION GC CENSUS TRACT ` ' <br /> i <br /> Owner's Name `z: . �rt;G C:/�r J °�; ?_ ._ _ Phone. <br /> Address G G v City <br /> 3 Contractor's Name License ��asS�rl77 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN I I RECONDITION / / DESTRUCTION. /� <br /> PUMP INSTALLATION IT-1 REPAIR / MP REPLACEMENT /? <br /> j Other .ITTr <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia-4.6fr.Well Excavation <br /> Domestic/private Drilled Dia.2f Well Casing <br /> Domestic/public Driven Gauge ,of Casing <br /> Irrigation Gravel Pack Depth+of'Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other 'iixformation ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H•P• <br /> PUMP REPLACEMENT: f-7- State Work Done <br /> PUMP�REPAIR: Done- - VZ <br /> '�` " " <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 tr to the best y knowledge and belief. <br /> SIGNED -d TITLEi��-v�c�r / <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G 0 N ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY N DATE L �3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 4/72 1M <br />