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all-3 <br /> FOR OFFICE USE: N JOAQUIN LOCAL HEALTH DISTRI( <br /> 160!WE. Hazelton Ave. , Stockton, Cif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y3, y3yp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> application is hereby made to the San (Co <br /> aquineLo alriplica HealthtDistrict for a permit to construct <br /> tnd/or install the work herein described. This application is made in compliance with San Joaqui <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> wner's Namez <br /> �%�a .�,�,�-- <br /> ddress Phone <br /> City <br /> ontractor's Name �al <br /> License U Phone ? <br /> y oy69G <br /> YPE OF WORK (Check): NEW WELL /% DEEPEN /% RECONDITION /- /DESTRUCTION /- <br /> PUMP INSTALLATION —/—/ PUMP REPAIR /—/—PUMP REPLACEMENT /07 <br /> Other /-7 <br /> t <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> 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 <br /> Other Rotary Type of Grout <br /> Other�! /J Other Information <br /> W INSTALLATION: Contractor <br /> Type of Pump = " H. f <br /> IMP REPLACEMENT: State Work Done/ <br /> JMP REPAIR: /% State Work Done <br /> :STRUCTION 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 /> A 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 /> :LL DRILLERS REPORT of the well and notify them before putting the1 in use. The above <br /> ,formation <br /> ?iAs-'true <br /> ' Otto the <br /> / best of my knowledge and belief. <br /> GNED --CJS ?/Y.(`f� �4�F TITLE �t <br /> (DRAW PLOT PDY ON—REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> 1DITIONAL COMMENTS: <br /> PHASE II GROIri <br /> UT INSPECTION P E FIN NSPECTION <br /> SPECTION BY DATE INSPECTION B DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />