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}JOAQUIN LOCAL HEALTH DISTRICT <br /> 1JR ( ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,3--335 <br /> -� - --- <br /> 40 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 7-1,2 _,.;73 <br /> (Complete In Triplicate) <br /> 1 _plication is hereby made to the San Joaquin Local Health District for a permit to construct <br />,,.nc/or install the work herein described. This application is made in compliance with San Joaqufnf <br /> rty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CM ADDRESS/LOCATION `� � L. <br /> CENSUS TRACT <br /> u-er's Name Aa= 71 <br /> Phone <br /> ddress <br /> City,:! . <br /> oty-� <br /> �- ' ' <br /> ractors Name f } <br /> �` CL:� "�.�� C, License # <br /> Phone 411L- <br /> OF <br /> 1 `OF WORK (Check) : NEW WELL /Z7r-- DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> 3 <br /> T."JANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �O <br />_ Domestic/private Drilled <br /> Domestic/public Driven Dia. of Well Casing <br /> Gauge of Casing <br /> Irrigation 7zGravel Pack Depth of Grout Seal � <br /> Other ! �[f <br /> Rotary Type of Grout <br />- Other Other Information <br /> T3� INSTALLATION: Contractor - P C4 <br /> Type of Pump <br /> H.P. <br /> W REPLACEMENT: / / State Work Done <br /> R,'_ REPAIR: / / State Work Done <br />'7RUCTION OF WELL: Well Diameter Approximate Depth <br />}� . Describe Material and Procedure <br /> Irl reby agree to comply with all laws and regulations of the San Joaquin Local Health .District <br /> L6 the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> i#. rmation is true to the best of my knowledge and belief. <br /> GNED <br /> TITLE <br />- ._(DRAW PLOT PLAN ON REVERSE SIDE) ! ` <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> FICATION ACCEPTED 8Y 4_7 <br /> rIONAL COMMENTS• ] D '=�G,- s' _ <br /> PHASE II GROUT-INSPECTION I <br /> CTION BY PHASE / ION <br /> DATE INSPECTION BY <br /> ALL 426 A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE;C � <br /> E H 1425 1'/ 7/72 1M <br />