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SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE f�01 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: '(209) 466-67$I <br /> ICATION FOR WELL CONSTRUCTION"OR PUMP PERMIT Permit`No.72-- z- <br /> IS PERMIT EXPIRES 1 YEAR <br /> DATE ISSUED , Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby' 'de `t the-Sari Joaquin Local Health District fora :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 andVthe Rules-and Regulations of ,the San Joaquin Local Health District. j <br /> JOB ADDRESS/LOCATION Li cl 60 W-4 TER4 0 A P CENSUS TRACT ' <br /> owner's- Name / <br /> f I.+GC� Phone I ��_� <br /> Address Gi 24 c� � �`- L ae p City <br /> Contractor's Name t&&111 RSA4- Gc-H S izeP4 Licensey�jPhone 't,, c <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN I-7 RECONDITION I_7 DESTRUCTION �T <br /> ALH <br /> PUMP INSTLATION PUMP REPAIR./ / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK Ig-al SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c <br /> Industrial _ Cable Tool Dia. of Well Excavation G► <br /> Domestic/private Drilled Dia. of Well Casing ti <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Grave.l. Pack Depth. of Grout. Seal <br /> Other _ Rotary Type of Grout . <br /> Other Other Information <br /> PUMP' INSTALLATION: Contractor c � <br /> Type of Pump H.P. S� <br /> PUMP REPLACEMENT: L_1 State Work Done , <br /> _ � I <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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 thein before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. _. <br /> SIGNED ►TITLE - - <br /> (DRAW nOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE �'6 �^� • <br /> ADDITIONAL COMMENTS: INSPECTION <br /> PHASE II GROUT INSPECTION P <br /> INSPECTION BY DATE INSPECTION BY DATE Y <br /> CALL_ FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS 0 . <br /> E H 1426 4/72 1M <br />