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SAN JOAQUIN RACAL HEALTH DISTRICT <br /> F,0F. OFF TCI: USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 u y3.,d <br /> 73 r ,:s-a, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F •3a 7-3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No, 862y�and he Rulers and a ulations of the San Joaquin Local Health District. <br /> ,0 d A <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _TI�1lIL�1! -r�...�Sf 11/9,r-PC: 74h - / - - Phone <br /> Addressr'Lr + T^ City�� r fs <br /> Contractor's Name + C' rS" C License , Phone �� -d �� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN,/__/ RECONDITION '/ { DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other ! / <br /> DISTANCE TO NEAREST: SEPTIC TANK e dd SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation d <br /> Domestic/private Drilled Dia. of Well Casing 'r <br /> Domestic/public Driven Gauge of Casing e y <br /> Irrigation Gravel Pack Depth of Grout Seal' �4.i'b <br /> Other Rotary Type of Grout R <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DF�RTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to a es Lf m nowledge and belief. <br /> SIGNET? TITL ��- <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY elo- DATE <br /> -- - -- _ - <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. ' <br />�_ E H 1426 _ 5/731M <br />