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SAN JOAQUIN LO�AL` iffiALTH 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. rye!-)_f'✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (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 /> County Ordinance No. 1862 and the' Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z�23.7 CENSUS TRACT <br /> Owner's Name Phonej��/� � � <br /> -- <br /> Address �Q� City <br /> Contractor's NameGCS i� �-4 ;_License # oJJ4'o Phone <br /> _ - <br /> TYPE OF WORK (Check) NEW "WELL /ODEEPEN /_% PRECONDITION /_7 DESTRUCTION /_7 <br /> PUMP' IN-STAL=IONS/ "'PIlMP"REPAIR J -/ 7-PUMP"REPL�iCEMENT %� <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC-TANK. SEWER LINKS PIT PRIVY <br /> i SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> x r <br /> INTENDED USE TYPE OF WELL 1 CONSTRUCTION SPECIFICATIONS v <br /> _ Industrial I/Cables Tool Dia. tof, Well Excavation ��" <br /> Domestic/private Drilled t. Dia, of:•Well Casing <br /> Domestic/public Driven1e .1 Gauge cif Casing <br /> Irrigation , <br /> - ----- <br /> .• : . Gravel P ck .Depth of Grout Seal - `�• <br /> Other Rotary —"Type of Grout ., <br /> - _ <br /> ---- , ther Other. Information <br /> PUMP INSTALLATION: Contractors k <br /> ' Type; of;Pum H.P. <br /> PUMP REPLACEMENT: % / State Work Done <br /> PUMP REPAIR: <br /> /. / State Work Done <br /> ,,� ESTRUCT-ION�OF• WELL:_-:"Well-rDiameter�—� ^_ ;.� <br /> -p _.... y. " -•- - .- � = W: " 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 •o€ 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 /> k SIGNED �" -r�Yy TITLE • <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 .GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY , '- DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />