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J—N JOAQUIN LOCAL HEALTH DISTRICT`!) <br /> FOR.OFFICE USE. 160 . L. Hazelton Ave. , Stockton, Cali . � dl'k <br /> Telephonet (209) 466-6781 �J <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: ' _,3T W <br /> THIS PERMIT''EXPIRES':1-YEAR FROM"DATE ISSUED Date',issued T: -7.3 <br /> : (Complete In Triplicate)' <br /> Application is hereby made "to the`.San Joaquin`Local'°Health District for a permit to d6nstruct <br /> and/or install the. work herein described. This application is made..iii compliance 'wtitFi "San Joaquin <br /> County Ordinance No, 1862 `arid'-tt a Rules <br /> and -Regulations of the "San `Joaquin Local Health District. <br /> OB ADDRESS/LOCATION ,% P <br /> lJ�-- f , _- .�A CENSITS TR.ACT <br /> ergs. Name _. d %r�z: .'' ;D � r�LC. e1 •. 'Phone <br /> Address r .City <br /> Contractor s' Namte License �� �1 /Phone ; '- <br /> TYPE OFtWORK; (Che ck): NEW WELL / DEEPEN /_% RECONDITION /� DESTRUCTION /_7PUMP ;TMST, � TION /�] PUMP REPAIR / / PUMP REPLACEMENT : /-7 <br /> 1 — <br /> DISTANCE TO`! NEAREST: SEPTICsTANK SEWER'LINES PIT PRIVY <br /> SEWAG& DISPOSAL.,.FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDf,D USE TYPE'PF WELL CONSTRUCTION SPECIFICATIONS � <br /> Indus'trial Cable Tool Dia. of Well Excavation' � <br /> omestic/private Drilled Dia. of Well Casing Q <br /> omesti'c/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary - . Type of Grout _ ,2Q2 -22:L,,J� <br /> Other Other Information <br /> PUMP INSTALLATION°:_ `, Contractor <br /> Type .of Pump H:P.. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done ' .i. <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and !P,rocedure <br /> I hereby agree to comply-w.ith all laws acid regulations of. the San.Joaquin Local Health District <br /> and the State Lof, 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 /> y ° <br /> information is true to the best I m knowledge a_nd, belief,, _ <br /> SIGNED f <br /> __ �G���- . .._, : - _� , TITLE <br /> (DEA -RLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED.;BX DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY., DATE •�, "]j IN BY DATE Q ,S'•71 <br /> CALL FOR A GROUT INSPECTION.,PRIOR'_TO, .GRO.UTING:AND.FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />