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'" "• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Ston-ktoa, Calif.. <br /> i! Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE ,1SSUED Date. Issued/ - 7 L <br /> IE (Complete In Triplicate) . <br /> Application is hereby made to the 'San Joaquin Local Health District for a permit to construct " <br /> and/or install the work'hereia described. This application is made in compliance with San Joaquin <br /> I <br /> County Ordinance No. .1862 and the Rules and Regulatiots 'of the Sdn Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i S' CENSUS TRACT ' <br /> 4 <br /> Owner's Name �1 (J rho ne <br /> Al- <br /> Address <br />� <br /> Contractor's Name �is l'� /4! �1' /r I z - License 24f rhonej/-� ;iZZP;�, <br /> II <br /> is <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION DESTRUCTION I�T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> i Other / / <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISF SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> li OF WELL � <br /> INTENDED :USE �� TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> Industrial— Cable Tool Dia. of Well Excavation <br /> - Domestic/private. Drilled Dia, of Well Casing 6* <br /> Domestic/public 11 Driven Gauge of Casing - <br /> Irrigation Gravel Pack Depth of Grout Seal U <br /> Other 1� Rotary Type of Grout:' --ff,2z 471.1 49U <br /> 1� Other Other Informat on` <br /> :0 Ate, <br /> F I W <br /> PUMP INSTALLATION: lContractor <br /> Type of Pump H.P. a <br /> PUMP REPLACEMENT: �;I / / State Work Done <br /> PUMP REPAIR: i� / / State Work Done <br /> ,)3ESTRUCTION OF WELL:X <br /> Well Diameter Approximate De th <br /> Describe .Material and Procedure <br /> I hereby agree to comply with alT laws nd 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. t _ <br /> SIGNED <br /> TITLE / f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,I FOR DEPARTMENT USE ONLY <br /> PRASE I 6 - <br /> A, f <br /> I APPLICATION ACCEPTED BY DATEADDITIONAL COMMENTS: i' ' o aPHAS IpG OUT ZN TION x. <br /> PHASE TII F NAL INSF <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GRdU NSPECTION PRIOR 0 GROUTING AND FINAL INSPECTI <br /> � E � 4I7'2 1M <br /> H 1426 <br /> E I� <br />