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FOR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FIC USE: 1601 E. Hazelton Ave- ,� Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> '113-179 P <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED-.� -Date Issued �L`"1 Z-73 <br /> (Complete In Triplicate) <br /> 43 r�o0 y <br /> Application is hereby made to the San Joaquin Local Health District for a permt to construct ! <br /> i <br /> and/or install the work herein described. This application is made in compliance with San Joa uin <br /> County Ordinance No 862 and' he ah Rtions of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION !rte <br /> (� 'I CENSUS TRACT <br /> Owner's Name e� 4CL fcC t 17 J''QS ` u <br /> � <br /> Address Phone <br /> CitycG <br /> Contractor's Name <br /> T License # hone 21, <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN __ . ... ' <br /> RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION _/ / PUMP REPAIR / PUMP REPLACEMENT <br /> Other.-/ / �"/k /? <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE`PIT1 <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of CONSTRUCTION SPECIFICATIONS <br /> Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Irrigation <br /> Domestic/public t Driven <br /> Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Other a I Rotary Type of Grout <br /> 'r Other Other Information <br /> PUMP INSTALLATION: Contractor 1v <br /> Type of Pump • �' <br /> _ � <br /> PUMP REPLACEMENT: /. / State Work bone <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> 4 <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lnd the State-of California pertaining to or regulating well construction, Within FIFTEEN DAYS { <br />►fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them, fore putting the well in use. The above <br />.nformation is true to the best y kn ledge an belief, <br /> IGNED <br /> (D PLO TLE <br /> ON SE SIDE <br /> HASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DIlITiONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTION PIAS FINAL I <br /> ISPECTION BY DATE NSPECT N <br /> INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI N. DATE <br /> E H 1426 <br /> 7/72 1M <br />