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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI. 'OFFICE USE: � 1601 E. Hazelton Ave. , *ockton, Calif. <br /> -- Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7� <br /> (Complete In jTriplicate) <br /> Application is hereby made to the San Joaquin LocaHealth District for a permit to construct <br /> l <br /> and/or install. the wont herein 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 - C G D ® /') CENSUS TRACT ' <br /> Owner's Name f'T' S S i4 LL N E t Phone <br /> Address 74- C o e h-R A f n -_ __ City <br /> Contractor's Name � License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION I� <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT /? <br /> Other 6k I J 'Z„ 7sla.G+- <br /> iM <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> V <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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor iF <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: { / State Work Done <br />? . <br /> PUMP --e � State Work Dane <br /> tEPAIR• / <br /> ,DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Pro6edure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Heath District <br /> f 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 themj� .efore putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> TITLE,O-," <br /> SIGNED <br /> ..°e��- <br /> ( W PWT PI. ON REVERSE SIDE <br />{ FOR '' TMENT USEONLY ^7 <br /> tp PUASE I C RATE G - 7��` 7f <br />` APPLICATION ACCEPTED .BY -- <br /> '' ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 1I INSPECTION BY — DATE I-S— <br /> CALL FOR A GROUT INSPECTION PRIOR •TO GROUTING` AND FINAL INSPECTION. <br /> r u 7A99 f 5/731.M <br />