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SAN JOAQUIN, LOCAL 11FALTi STRICT <br /> FORpUFFICE USE: 1601 E. Hazelton Ave.:,-Stoc�Xon, Calif. / f <br /> Telephone. .(209) 14' -67$1 73_z�-r(,(! <br /> APPLICATION- FOR WELL CONST�R.lCTION OR. PUMP PERMIT Permit No. <br /> Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate' { <br /> F ..(Complete In Triplicate) " E. <br /> Application is hereby made to tdecribedan ��uThisocal Health applicationDistmade inr <br /> rcompliance with San Joaquin <br /> and/or install the work herein scribed.quThis <br /> County Ordinance No. 1862 and the .Rules and Reg lations 'af the San Joaquin Local Health District. +4' <br /> zC �, - CENSUS TRACT"_ <br /> JOB ADDRESS/LOCATION I <br /> Phone <br /> Owner's Name <br /> City " <br /> Address 'Q ' <br /> t , f <br /> License # Phone <br /> contractor's Name o , <br /> Check NEW WELL * DEEPEN -/ / RECONDITION /� DESTRUCTION /_7 <br /> TYPE OF WORK (Check) . <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT IT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf_� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION; <br /> SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavati ' <br /> _ Industrial •� <br /> Drilled Dia. of Well Ca <br /> sin <br /> Domestic/privateDriven Gauge of Casing... . . <br /> Domestic/public o <br /> Irrigation (/gavel Pack Depth of Grout Seal <br /> Other <br /> tar Type of Grout ' r'-�-,-..•.--a — '�/+sr "�� <br /> y �. <br /> .,�,__.._ T_r------'�- •� <br /> Other to <br /> GLW v r <br /> PUMP INSTALLATION: 2��ontractor 1 H.P. , <br /> f Type of Pump <br /> 4 PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / w State Work Done <br /> pESTRUCTION OF WELL: Well Diameter -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 /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> E <br /> PHASE I ; AT <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMEN : ``mss �� <br /> p 0 T INSPECTION PHA` INSPECTION <br /> ! INSPECTION BY DATE INSPECTION BYTE <br /> CALL FO R SPECTION PRIOR TO ROUTING AND FINAL <br /> IN C �• 4/72 1M <br /> E H 14 6 / <br />