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s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS, 011 GE USE. :F 1601 E. Hazelton nve. ,1'Stoekton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permi. No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 16'70 <br /> tade (Complete In Triplicate)Application is herebyto the San Joaquin Local Health District for a permit to construct . <br /> and/or install the workherein 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 Dis4rict. <br /> ij <br /> .TOB ADDRESS/LOCATION ® �lQ�"�1 Sa<e Xa CENSUS TRAA CT . <br /> i <br /> Owner's Name r.[/r L !°l M �� ! ( / Phone -6 E-_ 1;2 vZ 9 <br /> r <br /> Address i� �ct r s" P City ' :I. <br /> -15 <br /> s, <br /> Contractor's Name <br /> ° cense #A ft, Mone '7E/�-3Z2-r"' <br /> TYPE OF WORK (Check): ANEW WELL DEEPEN / / RECONDITION/ / DESTRUCTION /-71 �n <br /> PUMP INSTALLATION LS;F 1'1JMP REPAIR / / PUMP REPLACEMENT ,� <br /> Other I J W <br /> DISTANCE TO NEAREST: SEPTIC TANK jJ ,j--SEWER LINES PIT PRIVY <br /> 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 <br /> r Domestic/public t' Driven .a Gauge of Casing �� <br /> X Irrigation ii Gravel Pack Depth of Grout Seal - <br /> Other H Rotary Type of Grout, I� <br /> iI Other Other Information <br /> PUMP INSTALLATION: Contractor ,(e <br /> Type of Pump ,^ HPC...: <br /> a _ <br /> PUMP►REPLACEMENT.--' State <br /> State Work Done <br /> PUMP `tE AIR: ~"%.T ,/ / State Work Done <br /> ,DFCTRUCTION �OF WELL: ! „'Well Diameter Approximate Depth <br /> Describe Material and Procedure �N <br /> f I hereby- agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> and the Stateaof California pertaining to or%regulating, well='coxistruction. Withi" --'FIFTEEN DAYS <br /> after completion of �yTw on anew well, I will furnish'-t_he"Sai�'•Joaquin'Local Health District a <br /> WELL-'DRILLERS REPORT, of the well and notify them beforei" ttfng the hell 'in use, The above <br /> information is true to'j.the best of my knowledge and belief. <br /> I <br />! SIGNED ----- . .-''' TITLE <br /> i; DRAW PLOT PLAN ON REVERSE SIDE 0 <br /> 'i FOR DEPARTMENT USE ONLY <br /> w PHASE I !�/ <br /> APPLICATION ACCEPTED BY DATE ---�� <br /> ADDITIONAL COMMENTS: <br /> PHASE .II .GROUT INSPECTION A . PHASE II FINAL .INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIdR TO GROUTING AND FINAL INSPECTION. <br /> e, <br /> E H 1426 �� ?�, f. _a. .. °. �M15/731M <br />