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S, JOSQUIN LOCAL HEALTH DISTRICT� <br /> k_ ) OFFICE USE: 160.1 r. Hazelton Ave. , Stockton, Ca? `..i <br /> Telephone : (209) 466-6781 <br /> APPLICATJ'ON FOR WELL CONSTRUCTION OR PU111; PERMIT permit No. J vim' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Is;ucd <br /> (Complete In Triplicate) <br />� )iication is hereby made to the San Joaquin Local ,Health District for a permit to construct <br /> 3:x.1/or install the work herein descrii)._d. This application is made in compliancc with: San Joaquin <br />;ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local I1calth District. <br /> I(,-. ADDRESS/LOCATION << _31UCENSUS TRr1CT <br /> h^.er`s Name Phone <br /> Lddress c..j1. �� <br /> L-'t:a�l i-I (. City <br />:(.,tractor's Name: <br /> License 1 / _ Phone �- <br /> I-E OF WORK (Check) : NEW WELT, / / DEEPEN / J RECONDITION /_/ DESTRUCTION /7 <br /> +� • PUMP INSTALi-ATION / / PUMP REPAIR REPLACEMENT <br /> Other /__/ <br /> I TANCE TO NEAREST: SEPTIC T�Rd , —­ SEWER LINES PIT PRIVY <br /> -F <br /> SEWAGE DISP05;L_FIELD CESSPOOL/SEEPAGE PIT OTHER <br />�! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .9 <br /> Industrial _ Cable 'Tool Dia. of Well Excavation W <br /> Domestic/private Drilled Dia, of Well Casing —� <br /> Domcstic/public Driven Gauge of Casing <br />-�_ Irrigation ^ Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> r Other Other Information <br /> G_ra', INSTALLATION: Contractor <br /> Type of Puinp _ H.P. r-- <br /> UIQ.' REPLACEMENT: / / State Work Done <br /> p.�,�� �� ]jam,' ctlli� _ ►�'�. 'Gs <br /> U� I REPAIR: / State Work Done L <br /> EF-XRUCTION 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 /> E 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 /> Af-irmation is true to the best of my knowledge and belief. <br /> 1 . <br /> EGNED .��J� )fit. i Q� �. TITLE _ <br /> (DRAW f4,OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> iASE I <br /> ICATION ACCEPTED BY DATE <br /> 7 :TIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE b AL INSPECTION <br /> 4SPECTION BY C DATE INSPECTION BYDATE- <br /> FALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS N. <br /> E H 1426 7/72 1M <br />