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. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton `Ave, , Sfocktou, Calif. <br /> Telephone: (209)• 466-6781. <br /> zm <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, y� <br /> THIS PERMIT .EXPIRES .1 YEAR FROM DATE ISSUED Date Issued � � _ <br /> (Co (-mplete In Triplicate) L0 -�3� --o,?Application is hereb � to the San .Joaquin Local Health District for a permit to construct <br /> and/or install the work her described. This application is made in compliance with -San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f % � �+ _ CENSUS TRACT <br /> Owner's Name Phone - p2 d 3 74 <br /> Address 1S7i/ City ' <br /> Contractor's Name License # ,gyp Phone 93dr-7��9CJ <br /> TYPE OF WORK (Check) : NEW WELL/-;?,/DEEPEN /_/ RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY U\SEWAGE DISPOSAL FIELD 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 >,9 d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type ,of Grout <br /> _ _. . ._. Other Other Information ' jp <br /> PUMP INSTALLATION: Contiactor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> TRUCTION OF WELL: Well Diameter <br /> PES Approximate Depth <br /> Describe Material and Procedure <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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> 4 TITLE <br /> " (DRAW PLOT PLAN`ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7S . <br /> ADDITIONAL COMMENTS: -�--- <br /> PHASE OUT INSPECTION P S I INAL INSPECTION <br /> INSPECTION BY = DATE � J INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND FINAL INSPiZZ6. <br /> E H 1426 4/72 1M <br />