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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktoa, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-- <br /> THIS <br /> Z THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued <br /> i (Complete In Triplicate) <br /> F Application is hereby made to the'San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with San Joaquin <br /> k County Ordinance No. 1862 and the Rules and Regulations -of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION Gc.• �dZ- Y CENSUS TRACT <br /> i <br /> Owner's -Name Phone <br /> Address City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN './ / RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION /% PUMP REPAIR /PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />° INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial �j Cable Tool Dia, of Well Excavation <br /> til } <br /> Domestic/private " Drilled Dia. of Well Casing -- - _ <br /> Domestic/public is Driven Gauge of Casing t <br /> I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout � E <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0 <br /> PUMP REPLACEMENT: �. ) <br /> State Work Done� 5�- ,,,�„�•��, 1,� � �{ _.._.-__• <br /> PUMP REPAIR: / / State Work Done <br /> PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j <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 i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofil°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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I Ii <br /> APPLICATION ACCEPTED BY, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROM INSP TION PHAS5 III ,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE O-- /0^'72, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />