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; `"� SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOFOFFICE USE: 1.601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (204) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUDE' PERMIT Permit <br /> ;IS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 2 73 <br /> (�` .. .LtE;�,QQ•. (Complete In Triplicate) ,:�03 —/CrQ -f'� <br /> Applica"t1ori is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anal/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> 30B ADDRESS/LOCATION - TRACT Sr <br /> ILr�j/ / <br /> Owner's Name Phone <br /> Address City , <br /> Contr'actor's Name License 4� %/ 3 Phone <br /> TYPE OF.WORIC (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /—f <br /> Other /_7 — y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY' 1 � �1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT VTHER <br /> kr <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSV <br /> Industrial Cable TooV' Dia. of Well Excavation f' <br /> Domestic/private Drilled Dia, of Well -Ca•sing N <br /> Domestic/public Driven Gauge of CasingJ�i,/�' <br /> G <br /> Irrigation Gravel <br /> Pack Depth <br /> ofGrout <br /> Seal <br /> iType <br /> Rotary y p oGL� <br /> R Other Other Information <br /> R 6 n-rta S- <br /> s R I P©clir <br /> PU"iT INSTALLATION: Contractor <br /> Type of Pump ---� H►P. <br /> f <br /> PUMP REPLACEMENT: /7 State Work Bone t <br /> PUMP UPAIR: / / State Work Done - <br /> .DFRTRbCTION OF WELL: Well Diameter Approximate Depth <br /> j,. - --- - Describe Material and Procedure <br /> i <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 is true to the best of my knowledge and belief. <br /> SIGNED ' TITLE <br /> IIW PLOT. PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br />' k <br /> PHASE I' 11 ------ <br /> APPLICATION AC-GEPTF.,DY - DATE- <br /> TZ7 <br /> ADDITIONAL COMNENTS _ 1. - t <br /> P11ASE1.11I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (��.�. DATE /d `24/77' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND -FINAL (INSPECTION. .,. <br /> + Inr_ ^ v{,\ _, • J , (��7�7M <br />