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�~ SJOAQUIN LOCAL HEALTH DISTRICT <br /> i.JR (ill ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> 17 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1-73.- Y3-.5­4_1 <br /> j._' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-/„2 -.7.3 <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br />•rid./or install the work herein described. This application is made in compliance with San Joaquin' <br /> o . ty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> C_ ADDRESS/LOCATION `� L (� zL�_1�i �L tit"y - �l%1. ._ CENSUS TRACT <br /> a-er's Name Phone;ro <br /> 3 <br /> ddress � � yL � �C � +, i1 � City,�F'2��-L�7'l <br /> of tractor's Name Ct: It -CILI> 0'-<) License # Phone E <br /> F <br /> Y7E OF WORK (Check) : NEW WELL /� DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> iPJANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> T INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> f a Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r `ti <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> Tom1, INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> Jl_ REPLACEMENT: / / State Work Done <br /> R_' REPAIR: J / State Work Done <br /> :.'7RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> trreby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> K. the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .ter completion of my work an 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 /> ,1`rmation is true to the best of my knowledge and belief. <br /> .GNED TITLE <br /> _(DRAW PLOT PLAN ON REVERSE SIDE <br /> � . FOR DEPARTMENT USE ONLY <br /> ASE I /--�- 'r <br /> 'RICATION ACCEPTED BY /.. D 7_!� ��� <br /> Z TIONAL COMMENTS: lei' <br /> �— <br /> PHASE II GROUT-`1NSPECTION PHASEr / ION <br /> SPECTION BY i DATE INSPECTION BY <br /> ALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTATIYX <br /> E H 1426 7/72 1M <br />