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C� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � 1601 E. <br /> Hazelton Ave. , Stockton, Calif. <br /> - r <br /> ;•,}:_ OI'l'it1; U5r:: Telephone: (209) 466-b7 <br />-_..-._ Permit No. 7�:.��!v <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PI:Ft�'IT <br /> _...._� Date 9L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate} permit <br /> I 'Health Joaquin iance with Saa Joaquin <br /> �Li"ou a slero 'y scie to tdescribed. , Thi.soapplication istmade inrcomp�ocal 11 <br /> the <br /> District. <br /> ias ,all tile- work herein ulatio�ns of the San Joaquin <br /> County Ordinance No. 1862 and the Rules and Reg ` .., <br /> .' CENSUS TRACT - <br /> 7OR ADDRESS/LOCAT IO'LL __ _ ' <br /> Ga F' Phone <br /> Owner`s Name city �� z. `{ f <br /> Address �'5�� � <br /> License 4� 2 ` �� Phone 6 (F' <br /> Contractor's <br /> RECONDITION- DESTRUCTION <br /> TYPE OF WOitK (Check) -. N0,4 WELL �� DEEPEN I / - pU�7I' REPLACEMENT /- <br /> PCi�I' Ii;S` I:LL�VfiON 1 / <br /> PUMP REPAIR <br /> G-h <br /> _ SEWER LINES ?IT PRIVY <br /> DISaA�� E TO �EAREST: S2P` iC CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DLSi'OSAL FIELD � <br /> J —.• , <br /> -- `-�J�i '�r 0?" WELL COiVSTr UCTION SPECIFICATIONS G <br /> ,. 'i l?NUs:;3 i Si. y L Cable Tool Dia. of Weil Excavation <br /> Industrial — Drilled Dia. of Well Casing <br /> Dorestic/private — --- Driven Gauge of Casing <br /> Dora c/public -- Depth of Grout Seal ti <br /> Irrigation Gravel Pack p 4, -..t <br /> _- Rotary Type of Grout <br /> ;ether. Other Information <br /> . Other <br /> Co«t'ractor <br /> i'u"."�' INSTrLI.ATI0i3: _ - <br /> -.._�--- Type of Pump <br /> Spate Work Done <br /> .zEPA-IR, State Work Done <br /> LUe1i <br /> -" Approximate Depth <br /> DFgTRUCTION 0t_ WELL: Well Diameter <br /> Describe Material and Procedure <br /> lth <br /> rict <br /> cal <br /> com l w tli all laws and regulations of the San ruction.LoWithiitaFll'TEENtDAYS <br /> 11�ercoy ,;r e <br /> to compl, <br /> and the State of California pertaining to or regulating well cons <br /> ;: ur com�le%ior: of my worms <br /> or, a c.ew well, <br /> I will furnish the San Joaquin Local Health District f <br /> tii LL D--",LEERS R=arORT of the well and notffY thm before pund tting the well in use. The above <br /> iuf.ur;kation is true to the best of my knowledge <br /> TITLE <br /> SIGN,D <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY f <br /> DATE <br /> cl 'i'Ll(,VZION AC::"TED BY � <br /> ADDITIONAL CO,iiENTS: - PHASE III/FINAL INSPECTION <br /> i'i:I�SE II C .Ot T INSPtiC' ION . INSPECTION BY DATE <br /> DATE r <br /> INSPECTION BY <br /> CALL ioa A GROUT INSPECTION Pj 16R TO GROUTING AND FINAL INSPECTION. 5/731.M ' <br />