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SAN JOAQUIN LOCAL kUJALT ? DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel ton.Ave.y� SE'ockton, Calif. <br /> Telephone: (209)-,466-6781 7Y <br /> APPLICATION FOR WELLlLCONSTRUCTION .OR PUMP PERIMIT Permit No. pi9 <br /> ` THIS PERMIT. EXPIRES 1'-YEAR TROM`bATEISSUED Date' Issued/0 <br /> (Complete In Triplic'ate)... . <br /> Application is hereby :made.it.o the--S.anFJoaquin�Local Health District. for a permit to construct <br /> and/or install the work herein described. This application is made in compliance withLSan Joaquin <br /> County Ordinance .No.: . 1862..and,the=Rules and Regulations-of the San Joaquin Local Health District. <br /> <- <br /> JOB ADDRESS/LOCATION 01-3 �; 011.5CENSUS TRACT <br /> Owner's Name _�; �� �S° !_ n .,. . :� -Phone i <br /> Address i� + ' f <br /> Contractor's Name Q2C/C. /Gj X75 ; License #ZcV 77VPhone. <br /> TYPE OF WORK (Check) : kNump <br /> EW WELL / DEEPEN/}/ RECONDITION /-7 DESTRUCTION <br /> �. <br /> INSTALLATION '/KFPUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> DISTANCE TO NEAREST: SEPTIC ,, AN <br /> TK / p 0 SEWE LINET�` PIT PRIVY J <br /> f SEWAGE DISPOSAL FELD` ,. / CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial it Cab-17e Tool Dia , of Well Excavation �� \ <br /> Domestic/private. Drii-led ""'"""`DiaLbf'"Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack .epth of Grout Seal / (� <br /> Other a;4 RotaryType of Grout �- <br /> Iyj } Other t Other Information <br /> '�c �j •ae ¢ E � 1 i <br /> PUMP INSTALLATION: i'Contractor <br /> yip <br /> .!Type of Pump i I H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: <br /> Well Diameter � � ApproximateDepth <br /> 'Describe Material and Procedure 1 <br /> %A ,• L_ <br /> I hereby agree to comply withal .:haws"-''andttegulations' of the San Joaquin Local Health District <br /> and the State of California pertaining—tVa do regulating well construction. With_inuFIFTEEN DAYS <br /> after completion of m ,i. o on a new well, i wal urnis the Sante aquin.Local Health District a <br /> WELL DRILLERS REPO of the well and notify them before putting the well'izi`'ise. The above <br /> information is a to, the be my k wledge and belief. <br /> i <br /> k - <br /> SIGNED TITLE <br /> (DRAW 1%-LbT PLAN ON REVERSE SID <br /> FOR DEPA4TMENT USE ONLY ,, <br /> PHASE I 1, <br /> APPLICATION ACCEPTED BY / DATE�,�� Z�~� <br /> ADDITIONAL COMMENTS: 11 <br /> PHASE II GROUT INS CTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE �d2 -lB"-7% =,-:INSPECTION BY DATE <br /> CALL FORA GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 14,26 li 4/.72. 1M <br />