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OFFICE SE: 5 ) UI-TOA' N LOCAL HEALTH DISTRICT n <br /> U ?6OI x.: ata zu•l <br /> ton Ave. , Stockton, CaI `. t . <br /> - Teiephone : (209) 466-6781 <br /> APPLICATION FCIt WELL CONSTRUCTION OR i'UNI, PERZMIT Permit tin. 7 <br /> 1J✓/� <br /> TIFIS- PEj?jjIT is;C'IRES l YI!r1A FROM DATE ISSUED <br /> Date I:;,ucd / I <br /> (Complete 1n Triplicate) <br /> rlication is hereby made to the S.in .:-jaquin Local Health District for a permit to construct <br /> IRMI/or install .ithe work herein descr.u) _,'_. This l ; <br />�o�nty Ordinance No. 1862 and the RLi� application is made ir. compliance with San Joaquin <br /> and Regulations oz the San Joaquin Local Health District. <br /> ADDRESS/LOCATION <br /> - � CENSUS TRACT <br /> er's Name <br /> Phone <br /> address _ -53 <br /> ,i. City <br /> �J <br /> tractor's Name _ <br /> 7: ] :�., 2 License it Phone 1G <br /> E <br /> -: OF WORK (Check) .- NEW WELL /�l i)I;`:PEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> 1 PUMP I.ISTALLATION / / PU11-T REPAIR <br /> /}(/ PUMP REPLACEMENT- <br /> Other ;_/ <br /> BT,kNCE TO NEAREST: SEPTIC T,L^�Y, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOj,/SEEPAGE PIT _ <br /> • OTHER <br /> INTENDED USE TPE OF WLL CONSTRUCTION SPECIFICATIONS <br /> Industrial' Cable Too! Dia. of Well Excavation W <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driv^n Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other _ Other Information <br /> INP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> ism REPLACEMENT= / / State Work Done <br /> _ 5 <br /> ' REPAID: �.4��� c4f+ ! ]j�ra •ct1l� _ �t 1arc 7,,. ! <br /> /I State Work Done L <br /> • 'i <br />`''"RUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> Thereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of 'California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> vr completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />[.L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 'rmation is true to the best of my knowledge and belief. <br />�J <br />,NED TITLE L <br /> (DRAW OT PLAN ON REVERSE SIDT)17— 151 <br /> 6E T FOR DEPARTMENT USE ONLY <br />'fU ACI TION ACCEPTED BY <br /> ITIONAL COMMENTS: DATE �� <br /> PHASE II GROUT INSPECTION PHASE b vAL INSPECTION <br />;PECTION BY DATE INSPECTION BY DATEyt <br /> '.ALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS N. <br /> E H 1426 <br /> 7/72 IM <br />