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JOAQUIN LOCAL HEALTH DISTRIG1 <br /> FOR OFFICE USE: 160 -E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /D JZ; <br /> F (Complete In Triplicate) <br /> _pplication 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 Joaquii <br /> ounty Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> SOB ADDRESS/LOCATION i /0 / _ (- F- � ���:;_: )I CENSUS TRACTS q 7 <br /> Fwner's Name <br /> Phone <br /> Address 'J <br /> City . <br /> Clontractor'a Name : -i License 111210 Phone/ - y <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_� RECONDITION /_/ DESTRUCTION _ <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> AL /-7 <br /> F Other / / — <br /> ,uISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER els <br /> ����;� \�.n f7` t;Tf't:- '(�/.. k ,-'t-'!'�,:� '(+"� 1.. .�, '��.>,..t7•o-(i ter' <br /> INTENDED DED USE TYPE OF WEL t CONSTRUCTION SPECIFICA 0ON <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> w Domestic/public Driven Gauge of Casing z. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Other Rotary Type of Grout V <br /> Other Other Information <br /> JMP INSTALLATION: Contractor <br /> e Type of Pump H.P. <br /> ,r'JIT REPLACEMENT: GSL I 'L`LS 4e. f J <br /> / State Work Done <br /> Y j h <br /> PUMP REPAIR: / J State Work Done <br /> F,7STRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> :hereby agree to comply with all laws and regulations -of the San Joaquin Local Health District <br /> �_id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of mywork on a new well, I will furnish the San Joaquin Local Health District a <br /> ["ILL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> _ 'formation is,true to the best of my knowledge and belief. <br /> ,LCGNED � TITLE •c <br /> •_a <br /> e- RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> rSE IPLICATION ACCEPTED BY - DATE t '� <br /> ..?DITIONAL COMMENTS: <br /> PHASE- II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ISPECTION BY DATE INSPECTION BY DATE � - <br /> F - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />