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4 '"� �! SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> ` S,; 1601E Hazelton Ave. , <br /> Stockton, Calif. <br /> FOS.uIFIG USE: . Telephone: (209) 466-6781 Permit No. 1� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> -- Date Issued Is <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED 2 - �Drl0�17 <br /> ' - (Complete- In Triplicate) <br /> Application is hereby made to the San Joaquin Loapplicati,on isDistrictcal Health made in coplianCetwith nSan uJoaquin <br /> and/or install the work herein described. This app <br /> t Ordinance Nlations of the Sats Joaquin Local Health District* <br /> County o+ 1862 and the Rules and Regu7- <br /> ENS13S TRACT <br /> r .8- <br /> ,IOB ADDRESS/LOCATION �. 1 <br /> Phone - <br /> 717 <br /> Owner's Name <br /> ° City � <br /> Address <br /> 9 5 ?� <br /> License �3 'hane ' <br /> Conractor� <br /> WORK_-(Check) : NEW WELL DEEPEN /�/ RECONDITION / / DESTRUCTION I�T <br /> 'TYPE OF. �;��c �� _ <br /> 4 �!?C)rj -A PUMP =INSTALLATION / / PUMP REPAIR / / PUMP .REPLACEMENT I <br /> - f LV O they -/ <br /> PIT PRIVY <br /> SEWER LINES OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK .. CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL•FIELD, I <br /> INTENDED U5E �. TS'PE OF WELL <br /> r CONSTRUCTION SPECIFICATIONS <br /> ��- `�`� Dia. of Wel]. Excavation / '• <br /> Industrial Cable Tool, t .. - <br /> �-�.- �.Dia._of Well Casing !� P <br /> Domestic/privat i"Af Drive ',a,,n '�' t �aug� af Gasing t <br /> Domestic/public �� s - I3e th sof Grout Seal D <br /> f Gravel Pack P : . <br /> irrigation � T ecaf Grout ` <br /> Rotary Yp _ '. <br /> Other _ _Other r Otherinfarmatioxt <br /> PUMP N5TALLATIOi3: Contractor <br /> PUMP REPLACEMENT: / / State Work Done <br /> �„. State Work Dane <br /> f PUMP PAIR,: � � /! . ..-..._. <br /> `f Approximate Depth <br /> I <br /> Dp.cTRUCTION1 OF WELL: Well_-piameter _ <br /> � .. Describe Material and Procedure � <br /> } <br /> I hereby agreetto comply VIth all laws and regulations of the San Joaquin Local Health DEN ct <br /> Within FIFTEEN DAYS <br /> and the, Stateof Cali€orr�i pertaining <br /> well,or rl will furnshegulating ethecSantJoaquin�'Local'Health `District <br /> i afterfcomplet�:on of my work- an <br /> WELL DRILLERS REPORT o€ thm before <br /> belief the wall in ruse F The above <br /> the- well and notify <br /> information is- true to the�best of my knowledge <br /> ITLE <br /> € SIGNED s (DRA PLOT P AN ON REVE SIDE <br /> p {} ARTMENT USE ONLYPRASB_V_ ATE <br /> f <br /> APPLICATION ACCEP D <br /> j' ADITIONAL COi _S _ P S II `INSPECTION _ <br /> T SEfI GROUT INSPEC N INSPECTIO ATE , <br /> INSPECT O DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO G QUTING AND FINAL INSPECTION. -5/73 <br /> 5/73 <br />