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SAN JOAQUIN LOCAL HT_ALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6751 <br /> V_"P_7 <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2-- 76 <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued 2- 6- -71- <br /> (Complete <br /> 71 <br /> (Complete In Triplicate) <br /> Application is hereyato the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -; a /1cx ., CENSUS TRACT <br /> Owner's Name �, .cr -- --- Phone G L <br /> Address [,�4`��- -�-�_ RQ. City <br /> Contractor's.Name � �P1L�LLC c1 License Phone <br /> TYPE OF WORK- (Check): NEW WELL 2OF DEEPEN-'-/--/- RECONDITION DESTRUCTION /_7T f <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK p/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD d CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �_ 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 Depth of Grout Seal S p <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor r` _ <br /> Type of Pump H.P. //rti <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 i true to the est of my knowledge and belief. <br /> SIGNED 4TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �, .__ DATE Z�",Zy "17-2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY J DATE �7 '). INSPECTION BY 9W DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING"AND FINAL INSPECTION. <br /> E H 1426 - -- - - — -- -- - -- 4/72 IM <br /> Y <br />