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a, ,SAKI JOAQUIN LOCAL —NEALTH DISTRICT <br /> FOR OFFICE USE: 1-6 1 E. Hazelton,`7A-,7.L,,., Star cto-', Cal-if. <br /> Telephone: (201) 455-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PETRIMIT Permit No. Z_ "jL <br /> a.. <br /> THIS PERMIT, E)dYIRES 1 YEAR' RROu i'.f",';";- ISSUED Date Issued 6 7Z <br /> (Complete In Ttiplicate) <br /> Application is hereby made to 'the San,:'Joaquin Local Health District for a permit to ,construct <br /> and/or install the work herein described. This application is made in compliance with San. Joaquin.. <br /> County Ordinance- No. 1862 and the Rules and°Regulaa'tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION GIZtJ 1 CENSUSTRACT <br /> Owner's. Name. //`'/. �_—�7 Phone ..5 <br /> � 7 � <br /> Address e 3 �J City: <br /> Contractor's Name 6� 0± ilS f�vr License # Phone � �✓� <br /> _ ;Zp9 <br /> TYPE OF WORK .(Check) : NEW WELL ,( DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION ",< PUM1 REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK O/ SEWER,LINES� y PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,C©/CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ,ti 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 Z4 <br /> Irrigation Gravel Pack Depth of Grout Seal -� <br /> Other Rotary a Type of Grout ' <br /> Other Other Informati <br /> PUMP INSTALLATION: Contractor, p, <br /> Type of Pump H.P. / ^ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:.- / / State Work Done <br /> .DESTRUCTION 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 A <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 an otify them before Putti the well in use. • e above °ya <br /> information is true to the best my knowlge an belief. <br /> SIGNED TITA:E <br /> DRAW P T PLAN ON RE RSE SI ) <br /> FOR DE ARTMENT Ut ONL <br /> PHASE I - <br /> APPLICATION ACCEPTED BY ' DATE ' <br /> .. <br /> ADDITIONAL COMMEN *e <br /> P T INSPECTION PHASE II/,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY BATE <br /> CALL FOR E ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />