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SAN JOAQUIY LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazeltonlr.Ave.' Calif.3 <br /> '(209)",A-66` 6781 <br /> Telephone: .3 <br /> ------------- ATPLICATION FOR WELL CONSTRUCTION,-OR PUMP PERMIT Permit No. 7 7 <br /> ---------- R6FROM,.DAT-E!�3T S SUED �.,Date'19§ued T <br /> THIS pERMjT,,-.EXPIRES,, I�YEA ` <br /> tc )41�t6 n9-',Tft-p1ic6te) 37 <br /> struce- <br /> Application i,is Y-hdreby .ito the,;-,,S.aa-:-J6aquin-Lo&a1 He��lEh, Dist-ftet if or,7a!-pe'imiV ,t0' d-6nn <br /> and/or install the work herein described. Thi 9 fapplic ation is"made-.in Colfip liatice,,vjth7'S&n-`Joaqui.n <br /> tions of the San t3oaquin-Local,:,lie'altlf i-Distrlct- <br /> County 4 ordinance��No-.­U8 6:2 ri and vther-Rule6'iarid i:-Re-g-ula <br /> _j <br /> .5. 27 <br /> CENsjj&:.,TRAC,T <br /> JOB ADDRESS/LOCATION <br /> I r, �%i� v�. <br /> A..l .4 <br /> Owner'.s�N imA <br /> Ci <br /> '0 <br /> Address 0'6 1) <br /> Contractor's Name -IV a <br /> License U Phone 9jF - 5 <br />—TyPE­OF-WORK z''(MFCK)'I NEW_VLI1 'DEE <br /> PEiF�/ 7PRECONDITION` - <br /> DESTRUCTION <br /> REPAIR '/ PUMP REPLACEMENTPUMP INSTALLATIONI PUMP <br /> other; / <br /> DISTANCE TO NEAREST`: SEFTIC'T �SEWER LINES PIT PRIVY <br /> .SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> - CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> TYPE OF WELL . <br /> Industrial.... Cable Tool Dia. of �Well Excavation <br /> Tivate Drilled Dia. of as <br /> Well ing h2f hl, A k" <br /> Domestic/p <br /> Domestic/public DriVen ' Gauge of' Cas <br /> Irrigation. Gravel Pack Depth.of Grout Se <br /> Type Rotary Typf Grout <br /> Other 0 <br /> Other ' Other Information <br /> PUMPi INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> -PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: I I State Work Done <br /> DESTRUCTION OF WELL: . <br /> 6- Approximate Depth 76 <br /> ;Well Diameter 6 -Y , <br /> Describe Material and Procedure __fA=L116L <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and I 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 Didtrict 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 TITLE <br /> (DRAT„] PLOT PLAN ON REVERSE SIDE) <br /> FOR D ARTMENT USE ONLY <br /> PHASE, I DATE <br /> APPLICATION ACCEPTED BY <br /> t ADDITIONAL COMMENTS: : <br /> PHASE If—GROUT INSPECTION P11A ff INNAL INSPECTIDN <br /> Nz'r <br /> INSPECT JL�ATEhu�— <br /> L' <br /> DATE <br /> ION BY D <br /> INSPECTION.�B_ <br /> CALL FOR A GROUT-INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 Q3— <br />