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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F9E OFFICE USE: 1601 E. Hazelton=`.Ave. .. St ockCon,' •Calif. <br /> Telephone: (209) -4W-6781' <br /> PLICATION FOR WELL CONSTRUCTION:".OR PUMP PERMIT. Permit No. 72--5 Y-3 <br /> gtt567 <br /> THIS PERMIT -MIRES•,l E.YEAR'FROM-.DATP,"ISSUED'I Date -Issued <br /> Applicat odliisA,hereby:madeito 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 1 <br /> County Ordinance.}No:=.,1862{i.arid%thi Rules and .Re'gulati'ons' of .the ,San 'Joaquin.-Local;.Health `District. <br /> =:`- -i "E:"q :; ' , r'�i :i ;fi`_� .to; <br /> JOB ADDRESS/LOCATION` '&rlf��?�9 T S C G1P111 G T CENSUS 'TRACT ' <br /> Owner'. Name`' HMAIVIA)f Phone <br /> Address G/�/4I]'%/_�� '� 13 S T, City 7GGX(7Gl4l <br /> Contractor's Name ��[1/AW zf0o/pl C6 License # 7e 162 Phone , I <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN / I RECONDITION /__7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /�J PUMP REPAIR / / PUMP REPLACEMENT I� <br /> Other., /. / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE� DISFOSAL ,FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well-Excavation 20 F <br /> Domestic/private Drilled Dia. of Well Casing _ /2 <br /> Domestic/public Driven Gauge of Casing _ /�_ _-T e�r <br /> 7 <br /> t=,�rrigation. Gravel Pack Depth of Grout Seal - j7' <br /> Other t—Rotary Type of Grout <br /> Other Other information ' t <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /_7 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 <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. ' <br /> SIGNED 6� ' TITLE . F <br /> ,» (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I __ .o n <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: /4Cl, ,7` er[a�o�r c <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION F <br /> INSPECTION BY DATE INSPECTION BY DATE lo ?� <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL TION <br /> E H 1426 �� 1I .1 <br />