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JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> JR OMICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> didTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J3_ s �54_1) <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 73 <br /> (Complete In Triplicate) <br /> lication is! hereby made to the San Joaquin Local Health District for a permit to construct <br /> nc/or installli the work herein described. This application is made in compliance wit: San Joaquin? <br /> o�nty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ADDRESS/LOCATION 7� it `' 4�•��� ,.�_,L,. �Z? j/, CENSUS TRACT ' <br /> er`s Name Phone ` ti ' �r ' <br /> �' ` tiC i ty <br /> , <br /> re s s J� <br /> i/ G <br /> tractor's Name License # Phone <br /> I OF WORK (Check) : NEW WELL /� DEEPEN /% RECONDITION /_% DESTRUCTION /7 _ <br /> PUMP INSTALLATION /_/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /J <br /> CANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> Irrigation �Gravel Pack Depth of Grout Seal r^ tr <br /> Other �! Rotary Type of Grout <br /> Other Other Information <br />� JI�D INSTALLATION: Contractor <br /> Type of Pump H.P. J G <br /> IJMP REPLACEMENT: State Work Done <br /> REPAA: / / State Work Done <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 HealthDistrict <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 />'�:LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 10rmation is true to the best of my knowledge and belief. <br /> C.tED t-/ n � <br /> TITLE <br /> --(DRAW PLOT PLAN ON REVERSE SIDE) I ► <br /> FOR DEPARTMENT USE ONLY <br /> AS`E I <br /> p ICATION ACCEPTED BY /. Ir D 7_/r - <br /> rIONAL COMMENTS: <br /> PHASE II GROU�'INSPECTION PHASE / V ION <br /> tLLCTIQN BY r DATE INSPECTION BY FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC <br /> E H 1426 7/72 1M <br /> it, �_ - - - <br />