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C) <br /> JOAQUIN LOCAL nEALTH DISTRICT <br /> 1601 E. Hazelton Ke. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUINP 111`,KMIT Permit-. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dat-o <br /> (Complete In Triplicate) <br /> ApplicativQ is hereby made to the San Joaquin Local Health District for a permit to cons[ c"�t <br /> and/or install the. work herein described. This application is made in compliance with San Jonqui <br /> Couaty Ordinapee No. 1062 and the Rules and Regulations of the San Joaquin Local Uealth Diapriet, <br /> j. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Le Phone <br /> Address City <br /> Contractor's Nate <br /> License Phone- <br /> TYPE OF WORK (Check) ; NEW WIELLDEEPEN Q RECONDITION Q DESTRUCTION /_7 <br /> PUMP INST_2__LATiON /_/ PUMP REPAIR' /--/ "PUMP REPLACEMENT - 17 <br /> Other <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES /:CCZSPIT PRIVY <br /> SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> j-N-6 1-,1) TYPE OF WhLL CONSTRUCTION SPECIFICATIONS <br /> I n d us L r i a I Cable Tool Dia. of Well Excavation <br /> XDoinie stic/private Drilled Dia. of Well Casing <br /> 1)oi iics Z:i c/p ub I i c Driven Gauge of Casing <br /> IrTigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> P&T INSTALLATION; . Contractor <br /> Type of Pump H.P. <br /> ,TIT REPLACEMENT: 0 State Work Done <br /> 'UMI? AEPAIR; State Work Done <br /> PFITRUCTION OF WELL.: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 0hereby agree to comply with all laws and regulations of San Joaquin Local Health District <br /> nad t4e State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> nVoer completioh of my work on a new well, I will furnish the San Joaquin Local Health District z <br /> !,,,'LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iniornaLion. is true to the best of .any .knowledge and belief. <br /> TITLE <br /> Sam) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMEONLY <br /> USE Y <br /> ?J, <br /> C';"A'loN ACG]--A�'TED BY _eDATE 9-n <br /> IONAL CGuii`,NTS. <br /> PUASE T1 GROUT T',1S?ECT'fON PHASE ITT/FINAL INSPECTYON <br /> &SPECTION BY-- DATE INSPECTION BY DATE <br /> CAI <br /> _1 OX GROUT�l N ELECT IAN-.R410i ITO�GROUTING -AND-FINAL-INSPECT I ONvn"v— <br /> =450 <br /> PLATE 25 <br />