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;a <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.', Stacktan, Calif. <br /> Telephone:... (209);.466'-67 ;1 <br /> APPLICATION FOR WELL CONSTRUCTION:OR PUMP PERMIT Permit No. '7,?--& <br /> $ ' <br /> THIS PERMIT EXPIRES-.1 YEAR:FROM. DATE ISSUED Dat6 Issued 7- 3. 7Z./ <br /> (Complete':In Triplicate) <br /> Application.is ,hereb made-to the.,,San-i Joaquin' Local Health Distract for a permit to construct <br /> and/or install the•work herein described. This-appl,ication is made in compliance with San Joaquin , <br /> County Ordinance.No: 11862 -�and, the-Rules- and Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ALc CENSUS-TRACT <br /> Owner!s 'Name', r_ y x Phone• <br /> Address / City I� ; <br /> Contractor's Name License # f r3 Phone ' <br /> ��. 1 <br /> 0 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECQND_ITION /-7 DESTRUCTION IJ <br /> ALi <br /> PUMP INSTLATION '/ / PUMP REPAIR PUMP REPLACEMENT /� <br /> Other � . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT MOTHER `I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout I� <br /> Other--- r ''"- Other Information <br /> PUMP INSTALLATION: Contractor E4 <br /> Type of Pump --- ' -- �M H.P. <br /> s � - <br /> PUMP REPLACEMENT: / / State :Work Done <br /> PUMP REPAIR: / / State Work Dome f7,Y <br /> ,DESTRUCTION OF WELL: Well' Diameter F � � t Approim t" Depth ' - <br /> Describe <br /> epth ' -Describe Material, and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Loca1'� 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 /> n4 , <br /> SIGNED „` �` TITLE t," <br /> RAW PLO LAN ON REVERSE SIDE) 1i <br /> FOR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,,J DATE' L <br /> ADDITIONAL COMMENTS: <br /> PnU II GROUT INSPECTION PHAS4,IWFINAL INSPECT-ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION,PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 4/72 1M <br />