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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T <br /> �R ,FOFFICE USE: 1601 E. Hazelton Ave. ICT <br /> , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> 3-as3 P <br /> THIS PERMIT EXPIRES I ,YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued, s4.3 <br /> lication is hereby made to the San Joaquin Local Health District for a 'permit <br /> i/or install the work herein described. This application is made in. compliance twith nSa Jo <br /> 4unty Ordinance No. 1862 and the Rules and Regulations of the Sail Joaquin Local Health n Joaquin <br /> h District: <br /> s ADDRESS/LOCATION S' 1 <br /> _ CENSUS TRACT <br /> mer's Name <br /> f Phone - 5 <br /> t Tress <br /> City <br /> �tra�ctor's Name <br /> License QZ. 010 Phone - �y <br /> 'PE OF WORK (Check) : NEW WELL /? DEEPEN _ <br /> _/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other PUMP REPLACEMENT / <br /> y / / <br /> P <br /> TANGS TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> E CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> 3i Domestic/private Drilled <br /> Domestic/public Driven Dia, of Well Casing <br /> _ Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> i Other <br /> r Rotary Type of Grout <br /> FOther' Other Information 4' <br /> IF <br /> r1P INSTALLATION: Contractor <br /> h JJ <br /> Type of Pump' H.P. <br /> REPLACEMENT: / State Work D <br /> r ..� •ne <br /> REPAIR: / / State Work Done <br /> i E <br /> STRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> [reby a ree to g comply with all laws and re Mations of <br /> d the!i tate of California pertaining to or regulating welleconstruction.San JoauinLacal Withinalth FIFTEENtrict DAYS <br /> r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the be t of my knowledge and belief. <br /> F)ED <br /> r TITLE <br /> r <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY <br /> TIONAL COMMENTS: DATE <br /> PHASE L II GROUT INSPECTION <br /> .'ECTLON BY DATE PHASE II FINAL INSPECTION <br />.. <br /> m INSPECTION BXDATE '" -a<3 <br /> rCALL A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> H 11426 " <br /> 7/72 1M <br /> �, I <br />