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-� <br /> SAN- O JOAQUIN LOCAL HEALTH DISTRICT R-- /C"0 �2 <br /> FOR .OFFICE_ USE: 1601 E. Haze;lton .Ave.. , StoCktou, Calif. <br /> '{ - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> Date Issued <br /> (Complete In Triplicate) i. <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br />! and/or install the work herein described. This' applica.tion is made in copp lance with San Joaquin <br /> County Ordinance No. 1862 ani the Rules and Regul ti <br /> ons,lof. the San Jo'aquijaLocal Health Dia riot. <br /> / <br /> JOB ADDRESS/LOCATION `' r-! f.�,��r ��u l t..}?�c �` <br /> MUS FAACT f- <br /> Owner's Name 29�} <br /> Phone <br /> A dress �2-7 <br /> Cit E <br /> r <br /> ,. y <br /> Contractor's Name <br /> +iense #1a•� G�O Phone ��'� � <br /> f <br /> ' - <br /> TYPE OI WORK (Check): NEW WELL '/? DEEPEN /? RECONDITION / DESTRUCTION /- <br /> VIVMP"INSTALLATION / PUMP`REPAI4, „� pUMP REPLACEMENT - I <br /> DISTANCE TO NEAREST: SE IC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.. of Well Casing f <br /> Domestic/public Driven Gauge of Casing �J I <br /> Irrigation �r - <br /> Other ?` <br /> g Gravel Pack Depth of Grout Seal f -Qr t' <br /> '� "� Rotary -TYpe of Grout <br /> Other <br /> _ Other Informatioii�. ....'� I <br /> t <br /> PUMP INSTALLATION: Contractor -r <br /> Type of Pum ✓ �;`eT � "" <br /> p r_ H.P. Q i. <br /> ` I <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP REPAIR: / / State Work Done <br /> F <br /> ESTRUCTION OF WELL: Well Diameter <br /> ' -- Approximate Depth - <br /> _ - Describe-Material and Procedure -�- _ T <br /> I hereby agree to comply with all lavas '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 /> 1 <br /> SIGNED r'\ 11 r ra-� ✓ TITLE -� <br /> (DRAW PLOT PLAN'ON.REVERSE SIDE <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> I ; <br /> APPLICATION ACCEPT' <br /> ED <br /> DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 14264/72 1M <br />