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SAN'JOAQUIN- LOCAL HEALTH DISTRICT <br /> i <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-116 V/ <br /> ' THIS PERMIT EXPIRES"I YEAR FROM DATE ISSUED q Date Issued 3-Jc3-73 <br /> a .� (Complete In Triplicate) _ <br /> Application is hereby made to the San Joaquin Local Health District for a pe1-7t oco a ut <br /> rmitr c <br /> t and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County-Ordinance No. 1862 acid the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14eeeXr! �/ ,1�, vra W /,,,� ��-{C <br /> ' CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 3 <br /> f u City <br /> Contractor's Name <br /> "6? (�1 CG License # Phone (2-173j <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_� RECONDITIOjW DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /� <br /> f Other / / -- <br /> i <br /> k DISTANCE TO NEAREST; SEPTIC"TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial t CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack De , <br /> Other � � Depth -of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> / / A State Work Done <br /> PUMP REPAIR: / / State Work Done {;*, <br /> ,DESTRUCTION OF WELL:`r` Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i <br /> I hereby agree to comply withiall 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 /> informat _ t e_ -o the best o€ y knowledge and belief. <br /> r <br /> SIGNED TITLE J <br /> . GSL I <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y DATE �4S <br /> ADDITIONAL COMMENTS: <br /> C PHASE II GROUT INSPECTION PHAS III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Lz <br /> CALL F'ORIA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 <br /> 7/72 1M � <br />