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C9 <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> `Jf 0'r F:CE US;:c� 1601 E. Hazelton Ave. , Stockton, calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PLrn? FF:RMIT Pcrnic a,s. 'S- <br /> Z3-3Q P <br /> THIS PERN.IT EXPIRES 1 YEAR FROM DATZ ISSUED Date Ltsftcr <br /> (Complete In Triplicate) 73 <br /> Application is hereby made to the San Joaquin Local Health District fora ,emit to ee+esatrort <br /> and/or install the work herein described. ' ."hie application is made in compliance Vith Sao Joaquin <br /> County Crdinance No. 1662 and the Rules and Regulations of the San Joaquin Lncal lbal-h astrl". <br /> JOB ADDRESS/LOCATION ' n e <br /> � D �•.I I�/' CENSUS TRtCZ <br /> Owner's Name �� � <br /> Phone �3� <br /> � �6 - � 7�G ;7V <br /> Address �6 �• /�jr✓�S -----} City <br /> Contractor's Name yL <br /> License <br /> TYPE OF WORK (Check): NEW WELL Y DEEPEN rQ RECONDITION /7 DESTRUCTION L7 <br /> PUS If:STAI L1TI0N <br /> .LL's PLW REPAIR /-7—PW RZpUCEM1iI�1T /7 <br /> Cthec _ <br /> DISTANCE TG `IE'•,2EST: SEPTIC TiC <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL F.ELD CESSPOOL/SEEPAGE PIT <br /> _ OTHER <br /> INTE Tr USE TYPE OF WELL <br /> Industrial CONS RUCTION SPECIFICATION <br /> -Cable Tool Dia, of Well Excavation <br /> Domestic/private <br /> Domestic/public Drilled Dia. of Well Casing_ Irrigation Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Other Rota <br /> ry <br /> i -pe of Grout VV <br /> Other Other Information <br /> r <br /> Pb--4P INSTALLATION; Contractor <br /> Type of Pump , <br /> H.P. <br /> PUS' REPLACE..`fENT: State Work Done <br /> PUMP 'tEPA1R: State Work Done <br /> .D gTRUCTION OF WELL: Well DLrmeter <br /> nd Proce <br /> Describe Material adure Approximate Depth <br /> I hereby 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> k;.LL DRI ERS REPORT of the well and notify them before putting the well in use. The above <br /> Linforma ion is u to the best of my knowledge and belief. <br /> ED <br /> Q TITLE t2 <br /> DRAM PLOT PLAN ON REVERSE SIDE) <br /> P,i.;SE I <br /> FOR DEPART:MNT USE ON Y��:�� <br /> .r <br /> A:I IC;ATION ACCL'?TED BY W ��V <br /> ADDITIONAL CON.'•;;=NTS: DATE <br /> ZI GROUT IN5iiiC:IO'' PHASE I'I FIN <br /> INSPECTION BY— DATE AL INSPECTION <br /> b '1 7" iNSPECTION BY DATE <br /> CALL FGR A GROUT INSPECTION PRiJ.0 I'0 GROUTING AND FINAL INSPECTION. <br /> L • .GAJ <br /> 5/73 im <br />