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JOAQUIN LOCAL HEALTH DISTRICT <br />�JR 30FICE USE: 1601 t. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> J3_53.5 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-/.,z -.73 <br /> (Complete In Triplicate) j <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nc/or install work herein described. This application is made in compliance with San Joaquinf <br /> o�:nty Ordinance No. 1862 and the Rules and Regulations Jof the San Joaquin Local Health District. <br /> ADDRESS/LOCATION �' L ` ,�• '�`` �-_,Z.�ti /,� <br /> ' CENSUS TRACT <br /> er`s Name 71 C+ Phone <br /> ddress �L L�,r'L,k� f}/ �l <br /> /l L City _ L '1 <br /> tractor's Name [ C`:".•' t: <br /> License 41 Phone <br /> E OF WORK (Check) : NEW WELL /7-�r__ DEEPEN /_% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEXENT / J <br /> Other -- <br /> CANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation, ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing IV <br /> Irrigation Gravel Pack Depth of Grout Sealr, ! . <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> J'� INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> THP REPLACEMENT: <br /> f <br /> State Work Done <br /> REPAIR: / / State Work Dore <br />'RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> reby 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 /> r completion; of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> T.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 /> GNED <br /> TITLE <br /> --(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> OrIONAL <br /> CA ION ACCEPTED BX COMMENTS: %f r'', ;/ DOE 7,/V <br /> PHASE II GROU-T—INSPECTION PHASE% / yP ION <br />'•S ECTION BY DATE INSPECTION BY <br /> ALL FOR A GROUT INSPECTION PRIOR ' <br /> TO GROUTING AND FINAL INSPECT � <br /> E H 1426 <br /> - 7/72 IM <br /> - - <br />