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S�JOR.QUIN LOCAL HEALTH DISTRICT' <br /> k ) OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Ca' A-. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUI11' PERIMIT Permit No. <br /> M <br /> THIS PEItNIIT EXPIRES 1 YEAR FROM DATE ISSUED Date Is;ued / ]- <br /> (Complete In Triplicate) <br /> 1 )lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> AL11/or install the work herein descriir d. This application is made in compliance with San Joaquin <br />',oanty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> TF, ADDRESS/LOCATION ' <br /> _•S _S � ,�- �.' "�� _,-J ,( CENSUS TRACT <br /> I—�er's Nama �. - ------— Phone <br /> kdciress a.3 .� .3 �..., 1._ <^ k'.(. City , <br /> V' <br />,i�tractor's Name License # j Phone <br />"FE OF WORK (Check) . NEW WEL1. ,—/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 _ <br /> �.- PUMP INSTALLATION / / PUMP REPAIR /j(/ PUMP REPLACEMENT <br /> Other <br />,7 TANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SIIEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .S> <br /> Industrial — Cable Tool Dia. of Well Excavation W <br /> Domestic/private Drilled Dia: of Well Casing —� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout: Seal � <br /> Other Rotary Type of Grout <br /> ►"'_ Other Other Information �- <br /> Una INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> Ute' REPLACEMENT: / / State Work gone <br /> P.«mss �- <br /> Lfl ' REPAIR: State .Work Done 4 <br /> E�-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> �. Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a7 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 /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />-0—,rmation is true to the best of my knowledge and belief. <br /> LGNED i La� � J c: TITLE <br /> r^ (DRAW P4,OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> SASE I <br />?PLICATION ACCEPTED BY DATE <br /> N ,TIONAL COMMENTS: cl> - T <br /> PHASE II GROUT INSPECTION PHASE b4U.NAL INSPECTION <br /> 1 <br /> 4SPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS N. <br /> E H 1426 7/72 IM <br />