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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.601 E- Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PIMP PERMIT Permit No. 73--6 fl� <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br />< Abp lica Linn is horvby .,::,c:c to the San Joaquin Local Health District for a permit to consLruet <br /> and/or in!;Call the: work herein described. - This application is grade in compliance with San Joaquin � <br /> ii County Ordinance No. IS62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> TOB ADDRI53/LOCITION CENSUS TRACT <br /> Owner's Nar,ie C H f �.ryt c y' Phone <br /> Address � , 3 O V1'_ �` D a n :s W a City 1 <br /> Contractor's Nano +, 14'. Licenses #/ y�"�hone cry, 7��n <br /> 1 TYPE~ OF WORT: (Check): NEW WELT. /% DEEPEN-/ / RECONDITION /_� DESTRUCTION /7 <br /> F'U.;P INSTALLATION / +/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> DISiAalCii TO ti1:Ai2EST: Si;i"LIC 'Cis: :: SEWER LINES PIT PRIVY <br /> SF'-N'AGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I\7'I:N1)ED-USi: i'.PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Da::.; s tic./r ublic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> --- Other Rotary Type of Grout <br /> Other _ Other Information <br /> -T INSTALLATION. calitroctox <br /> Type of Pump � ��. � ',' H.P. <br /> v <br /> S to ce Work Done <br /> ?U;T -4-t==IR: /.t/ State Work Done �, .✓ <br /> .DFcTRUCTION OF YELL: I"e11. Diameter Approximate Depth <br /> �— Describe Material and Procedure <br /> I i,ereov at;rcc ;.e co;.iply with all laws and regulations of the San Joaquin Local Health District <br /> .aua the $tati of Gzi i`ticrii:: partaining to or regulating well construction. Within FIFTEEN DAYS <br /> rifter any work on a new well, I will furnish :he San Joaquin Local Health District a <br /> '.;;.LL DRILLERS ;::PORT of ti,e well and notify them before putting the well in use. The above <br /> Lifornatiun is true to the best of my kr%oaledge and belief. <br /> a �.r•.'i TITLE ', ^[" <br /> �- (MAW PLOT PLAN ON RE MSE SIDE <br /> FOR DEPAMM—&T <br /> ION <br /> i`i; " w _.OliT I:;S?iiC'_IJ? PI31S II!1SPECTION 1 i <br /> p" i)i.'i INSPGC'TIO.f BY / DATE <br /> CvuLi I:�Si'i--CT10N 1'i�Iv.S TO GriQM[itG AND !-IN INS ECT GN. `i <br /> 5/731.[ <br />