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SAN JOAQUIN LOCAL FEALTH DISTRICT <br /> ton.,Ave. �,Stockton, Calif. <br /> FOR OFFICE USE: 1601 E. Hazel <br /> Telephorie: (209):,4667"67,81 <br /> P ICATION FOR WELL CONSTRUCTIONAORPUkIP PER-2141T Permit No. 72,-6 5 PERMIT =XPIRES l£Y.,EAR-_!FROMrDATE=;IS SUED ;,Date'--Is sued jj; �772-11 <br /> ' <br /> "ry, <br /> � <br /> . (Complete 1n�7-­T­T:vP.ut,&-t­) , "j".01,01"j )€ j , . <br /> .re y-'Imade-A to the,.��anqJ6aquintLo6al R&alth Disttict.kforl-a,:pe.-�Thit,.-to- COfigttucf <br /> Applicatiotibig�a,ho 'b de 3'jn,,compllance�with, San'tJoaquin <br /> and/or install the work herein described. Thi6L�-application,,isi,m <br /> C oun ty i:,Ord inaiiceoNo 18 6 2=-.and thi iRule I-,and s:,Re gula tion so :'tete San`-'.Joaquin�L ocal:!Health %Di <br /> 1'�KY_5_0 <br /> JOB ADDRESS/LOCATIO' 'i.%"CENSUSj-TRACT1.­, <br /> Z <br /> Cir <br /> X 77 t <br /> 7r :.Pho-ne <br /> .Owner!8Namd0l <br /> city y <br /> s Name License # Phone <br /> Contractor <br /> TYPE OF WORK (Check) i NEW WELL-/ DEEPENRECONDITION DESTRUCTION'::/-7 <br /> - /-7 <br /> REPAIR �X PUMP REPLACEMENTPUMP INSTALLATION PUMP <br /> ; .Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 INTENDED USE " TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial_ Cable Tool Dia.. of Well Excavation V-1 <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of' Casing <br /> Irrigation .Gravel .Pack . Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other' Information <br /> PUMP INSTALLATION: Contractor <br /> m . 1 <br /> Type of Pump H.P. <br /> PUMP, REPLACEMENT: State Work Done <br /> PUMP.REPAIR. <br /> _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 /> WELD DRILLERS REPORT of the well .and notify them before putting the well in use. The above <br /> inf8rmation is true to the best of my knowledge and belief. <br /> A- <br /> SIGNED TITLE <br /> _T ti <br /> (i)AAw PLOT 'PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> CI Y <br /> ADDITIONAL COMMENTS: PHASE III/FINAL. TNSPECTI-ON,.1-: <br /> U 11 GROUT INSPECTION <br /> PHA, _ <br /> INSPECTION By WVL��DATE INSPECTION BY DATE <br /> GALL FOR A, GROUT INSPECTION PRIOR TO GROUTING AND FINAL <br /> E A-14 iC': Ilk 4/h--1 im <br />