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SA,` JOAQU$N LOCAL HEALTH DISTRICT <br /> JI'I'.CE USE. � 160.1 E. 1;azclton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-r- <br /> THIS ;PF.RIiI'f EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Plication is hereby ..aide to t;ac San Joaquin Local Health District for a permit to construct { a <br /> I/or install the work herein described. , This application is made in compliance with San Joaquin :, <br /> anty Ordinance No. 1862 and the Ruler and Regulations of the San Joaquin Local Health District. . <br /> Q ADDRESS/LOCATION <br /> EI;SUS : ACT <br /> nen s N1me ! <br /> Gs/� ; <br /> Phone <br /> dress _ City Irt��.k <br /> ntractor's Name 04. K .ci _� L cense 433- Phone5f4^'OfG.Vj6 n_' <br /> PE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /-,T DESTRUCTION 1 <br /> PUMP INSTALLATION j< PLW REPAIR /_7PUMP REPLACMWT L7 .14 <br /> Other /`/ " 51 <br /> F? <br /> STILiCE TO NEAREST: SEPTIC Teti SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTI33R <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 7 Domestic/private W Drilled Dia. of Well Casing <br /> Domestic/public Driver Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Otho- '- Rotary Type of Grout , <br /> Other Other Information <br /> INSTALLATION: Contractor � 'Y <br /> Type of Pump H.P. )� �. t <br /> IP RFYLAC CIMEN:: / / State Work Done <br /> 9P 'kLPAIK: State Work Done tr' x <br /> ??s <br /> 7RUCTION OF WELL: Well Diameter � Approximate Depth :. �.'. <br /> Describe Material and Procedure <br /> Hereby agree to comply frith all laws and regulatlons of the San Joaquin Local Health District k �' <br /> l the State of California pertaining to or regulating well conetruction. Within FIFTEEN DAYS <br /> er completion of my work on a new well, I Will furnish the Sari Joaquin Local Realth District a <br />.L DRILLERS REof the well and notify them before putting the well in use, The above <br />'ormatio i rub to pf my nowledgee�and belief. " :, ,. <br /> NF <br /> ti <br /> C.'2, <br /> -- - DRAW PIAT PLAN Ori REVERSE E <br /> FOR DEPARTMENT USE ONLY ' <br /> SE I <br /> LICATION ACCEPTED BY ' DATE <br /> ITIONAL C4:0tENTS: <br /> PITA ' , II GROUT INSE� C:: PWR III FINAL INSPE=OK ~F <br /> PECTION BY DATE]_ INSPECTION BY . DATE <br /> r�Nj-s. enact A GAOUT INSPECTION PXIU: TO GROUTING AND SINAI. INSPECTION. ' <br /> c iI 1426 5/731M <br /> yr <br />