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SAN JOAQUIN LOCAL HEALTH DISTRICT <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. 72-- �L. <br /> THIS PERMIT•EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -5 <br /> (Complete In Triplicate) I .y7 3 5 <br /> Application is hereby- made,. to the San�Joaquin Local Health Distract 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 Ruleseand- Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / 0 1A1,11 J"6 -"• CENSUS TRACT <br /> Owner's Name 4 Phone Qj� IG <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .5.0 ft. <br /> Character pf so'sl to a de * f 3 e : Sand M Gravel F1 Sandy Loam F-1 Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Contractor s Name G� / j , C() License #r G GGZPhone k2-45-5-9 7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Z oa SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4__---D-omestic/private Drilled Dia. of Well Casing (a <br /> Domestic/public Driven' Gauge of Casing •_. „ .__.___ <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Other 4--�Ot ary Type of Grout <br /> Other Other Information t° <br /> PUMP INSTALLATION: Contractor -!S70WE44 COV <br /> Type of Pump <br /> _ G <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP REPAIR: <br /> State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> P ll/'i � Approximate Depth <br /> Describe Material and Pres ure IV I <br /> I hereby agree to comply with all laws and regulations :o'f the San Joaquin Local Health District <br /> and the State of California pertaining to or regulatingVwell 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 is true to the best of my knowledge and belief. <br /> 3 <br /> SIGNED TITLE <br /> - <br /> DRAW PLOT PLAN ON REVERSE SIDE)! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s <br /> ADDITIONAL COMMENTS: <br /> P INSPECTION PHA INSPECTION <br /> INSPECTION BY / DATE i-:=" -Z -z INSPECTION BY DATE <br /> —+oma,� ...� <br /> CALL FOR WE'OON PRIOR TO GROUTING AND FINAL IN TI7 <br /> E H 1426 4/72 1M <br />