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S JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OR OFFICE USE.: 16a'. Hazelton Ave. , Stockton, Cain <br /> J <br /> Telephone: (209) 466--6781 Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 uy <br /> THIS PERMIT EXPIRES 1 YEAR FR011 DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local health District for a permit to construct <br /> ,d/or install the work herein described. This application is-made in compliance with San Joaquin <br /> ,unty. Ordinance No. 1862 and the Rules and Regulations of ' the San Joaquin Local Health_District. <br /> )B ADDRESS/LOCATION _4/f,� f-p:,../-,J CENSUS TRACT <br /> rner's -Name /� / �. ,J rr?;r'� Phone <br /> !dress <br /> City / j <br /> n _ <br /> mtractor's Name _ _ j j-; % ::r„• _ ,�` �rJ< License l Vo cr' Phone ILL <br /> CPE 0 WOF& Check) : NEW WELL / / DEEPEN / / RECONDI ON /_/ DESTRUCTION <br /> PUMP INSTLATION PUMP REPAI / / PUMP <br /> ALREPLACEMENTt- <br /> Other / / <br /> AN NEAREST: SEPTIC TANK SE NES PI <br /> SEWAGE DISP05AL FIELD C SPOOL S .EP G OTHER <br /> INTENDED USE TYPE OF WELL OUST UC ION SPECIFICATIONS <br /> Industrial Gable Tool Dia f 11 excavation <br /> Domestic/private Drilled D' . o k' 11 Casing <br /> Domestic/public Driven aug f sing <br /> Y Irrigation Gravel c f Grout Seal <br /> Other Rota y pe of Grout <br /> t her Information <br /> [TMP INSTALLATION: ntractor <br /> T e of Piim i�<._,:. H.P. <br /> UMP REPLACEMENT: / / Work Done <br /> _ I <br /> Uk\iP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> ' Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction_ Within FIFTEEN DAYS <br /> after completion of•my work on a new well, I will furnish the”.San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the well and notify them before putting the well in use. The above i <br /> '_reformation is true to the best of my knowledge and belief. <br /> ;IGNED TITLE- Vii. r <br /> (DRAW PLOT PLAN ON REVERSE SIDE): <br /> FOR DEPARTMENT USE ONLY <br /> ?RASE I <br /> APPLICATION ACCEPTED BY ' �' ,s'�;cln DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION.. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />