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r <br /> SAN JOAQUIN LOCAL THEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton,Ave. Stocktoiz Calif. <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION..OR PUMP PERMIT Permit No. <br /> THIS PERMIT,EXPIRES 1',.YEARiFROM.DATE ISSUED Date Issued 0�9� <br /> Gum 41V4' (Complete In Triplicate) rE ��_ ��4 c12—cy1 <br /> Application: is,her by,.,.nade, to..the? SanrJoaquin 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 <br /> County- Ordinance- No.-.- I, 62- anted-t e}�R es•and,�Regu 1tii�o(na. ofa.-the S n Joa ui Lo al Health District. <br /> JOB ADDRESS/LOCATION CE SUS TRACT <br /> td ��i'y 4 � T :�� C xo .r•x,�r :"'f.t„i��3 �� r't � � :s,.,� r,'�t, <br /> Owner's .Name- 3' va-�'' Phone <br /> ( 41— 3� <br /> Address City <br /> ' Zs=:5L <br /> Contractor's Name I� h� cense # 'z7/ 00 Phone % 40 <br /> TYPE OF WORK (Check) : ! NEW WELL /�/ DEEPEN '/ / REG9ND.ITION>/_7 DESTRUCTION /_ <br /> ' PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> Other / / - <br /> DISTANCE TO NEAREST: EPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 ...._..�._ W <br /> INTENDED USE TYPE- OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation ,, <br /> Domestic/private �, Drilled Dia. of Well Casing <br /> Dome"s tic/public . ,-�T'""' :1?r3ven T Gauge of Casing <br /> Irrigation ;Gravel Pack Depth of Grout Seal <br /> Other - Rotary Type of Grout <br /> 71, Other i Other Information ' <br /> 9 <br /> PUMP INSTALLATION: Contractor ``; <br /> . Type of Pump : H.P. <br /> PUMP REPLACEMENT: ' ' J / State Work Done <br /> PUMP REPAIR: � /�/ State Work Done <br /> :DESTRUCTION OF WELL: Well Diameter / ! f 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,rb'efore putting the well in use. The above <br /> information is true toy the best of my knowl ge and belief. <br /> ! <br /> SIGNED p TITLE <br /> (DRAW;PLOT'PLAN ON REVERSE SIDE) <br /> I FOR DEPARTMENT USE ONLY <br /> .,PHASE I i <br /> APPLICATION ACCEPTED BY DATE ' <br /> .ADDITIONAL COMMENTS: ] <br /> PHASE II;IkGROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE Z, <br /> / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �, �� - 4/72 1M <br /> G <br />