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I <br /> JOAQUIN LOCAL HEALTH DISTRIC' <br /> FOR OFFICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUNA' PERMIT Permit No.73_ 5 y� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/,._?. <br /> (Complete In Triplicate) <br /> Application is herebymade to the San Joaquin Local Health District for a permit to construct. <br /> r:) <br /> d/or install the work herein described. This application is made in compliance with San Joaqui <br /> unty Ordinance No. 1862 and the Rules and Regulations of the San;Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONL- CENSUS TRACT `' <br /> yFdmer's Name G' Phone �8 <br /> dress 4 City ' €� <br /> 3 Contractor's Name4A"_�2License #/ /9 Phone -� <br /> W (Check) : NEW WELL DEEPERECONDITION DESTRUCTION _ <br /> TYPE OF RK N N 0 /_/ _/ / _/� % <br />! PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / <br /> 3 <br /> DISTANCE TO .NEARES : ' SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES POOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />` Industrial Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia, of Well Casing <br /> « . `F <br /> ` Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> } Other Rotary Type of Grout C <br /> Other Other Information <br /> JMP INSTALLATION: Contractor r ~ <br /> f Type of Pump H,P. 3 <br /> 'JMP REPLACEMENT: / / i State- Work Done <br /> REPAIR: / / State Work Done <br /> 1ZSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure <br /> F.1hereby 'agree. to comply with all laws and regulations of the San .Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> a ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i ELL DRILLERS REPORT of the.,well and notify them before putting thewell in use. . The above <br /> information is true to the b t of my knowledge and belief. <br /> GNEp TITLE ����J - <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> t :t"- DATE DC7"� - ' 7,� <br /> PLICATION ACCEPTED BY ':�=�,:,��.- �9,.� J <br /> ADDITIONAL COMMENTS: <br /> IN <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY .r DATE ,f'.,.r .q I`•s~' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> a u 1LI4 7179 im <br />