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SAN JOAQUIN LOCAL 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. 723 : ( ) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f k 7 ? 4 <br /> (Complete InfiTriplicate) � <br /> Application is hereby made to,,'the San Joaquin Lopal 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 /> y <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> +` <br /> Owner's Name <br /> i Phone <br /> Address City <br /> HLM111 DRILLING CO., INC. _ <br /> Contractor's Name ��/i�/C�� GtS, G�FC� z2clLicense # Phone - <br /> .. <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> I � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/;SEEPAGE PIT OTHER ' <br /> INTENDED USE TYPE OF WELL iCONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of; Well Excavation C <br /> Domestic/private I Drilled Dia. of;Well Casing <br /> Domestic/public I Driyen Gauge of Casing. �- <br /> Irrigation ,i Gravel Pack Depth of Grout Seal < r. <br /> Other ;1 Rotary �, Type of` Grout <br /> I Other + Other Information � <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done t ems _ <br />'PUMP REPAIR: S.tate�_WorkDorie. { Y. <br /> ESTRUCTION OF WELL: Well_Riame.ter— _ ., Approximate Depth ' <br /> Describe Mater al 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 oriregulating 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 4 <br /> informatio is true to the best o£_my_.knowledge.-and_.belief. <br /># SIGNED F TITLE" . <br /> (D P T PLANON REVERSE SIDE <br /> OR DEPARTMENT USE ©NLYIX` <br /> -- <br /> PHASEI _..._..__.,...___._- _.._..,�..�..._�-....-.,�.,.�....,.�.�, ._g,l�`L� --._�_ ...�......-......_...c....-��..�-- - - --- -•--._____--. .�-.-. <br /> APPLICATION ACCEPTED BY J t f"f fb DATE <br /> ADDITIONAL COMMENTS: <br /> --�-�--- - PHASE-II­GROUT-INSPECTION '" T " " -PNA �II FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE - <br /> CALL FOR A G T ftN�PRrTOr-` 0 G16UT AND FINAL INSPEC N. y� <br /> E H 1426 G�'o,a.. 7/72 1M <br />