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R - a.•. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 41,-11�1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR Pr PERMIT Permit No. <br /> �� � <br /> T PERMIT"El ~FROMZTE 'ISSUED Date Issued A-i7-7y. <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i JOB ADDRESS7MCRTTON 4- 7 1 1141-1CENSUS TRACT <br /> Owner's Name J �� Phone <br /> Address City[ <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check):," "s_NEW`WEI,L"�/ DEEPEN" .. <br /> /� RECONDITION /_� DESTRUCTION /'7 <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other / / -- <br /> " MISTANCE M NEAREST: SEPTIC TANK SEWER LINES PITPRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE' PIT,62�Q04- OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -� <br /> Industrial Cable Tool Dia, of We11;Excavation \ <br /> - Domestic/private Drilled Dia. of Well,Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other tRotary Type of Grout <br /> Other Other Information <br /> 1 <br /> 4. <br /> PUMP INSTALLATION: Contractor EH. <br /> Type of Pump P. <br /> PUMP REPLACEMENT: / / State Work Done1, <br /> E <br /> PUMP REPAIR: / / , State Work Done <br /> ESTRUCTION OF WELL: Well Di"aimete_r , =s-. Approximate Depth <br /> Describe,Material anis"-Procedure .N <br /> I hereby agree to comply with all Xaw ' and regulations of the San Joaquin Local Health District <br />,. and the State -of California pertaining to b,r regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well,' 'i will furnish the Saiz Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and ilotifylthem,before putting the well in use. The above <br />! information is true to the best of my1 knowledge 'and belief. ! <br /> SIGNED ? I <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY. <br /> 1 PHASE I <br /> APPLICATION ACCEPTED B _ c/ DATE <br /> ADDITIONAL COMMENTS: -�--- <br /> r <br /> PHASE II GROUT INSPECTION ,�w: '�. � W "PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 5-l b' '��'t �° 'INSPECTION�BY DATE <br /> r CALL FOR A OUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 7/72 1M <br /> 4 <br />