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SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> FOR OFFICE USE: . P/"'1601 E. Hazelton Ave. , Stockto.i, Calif. <br /> telephone: (209) 466--6791 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 12 <br /> (Complete In Triplicate) 203_ (r0-r7 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Lo al Health District. <br /> JOBsADDRESS/LO ATI //� / � - o�`f�`I � � <br /> /� � /0 f .(+�� CENSU5 TRACT �S <br /> n <br /> Owner's Name, ` Phone <br /> AddressCity <br /> Contractor's Name ,�,�- License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 4/ PUMP REPAIR / / PUMP RPLA MENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' o <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ���► <br /> S <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump H.P.. /p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / Sfiate 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_bApst of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R PE TMENT USE ONLY <br /> PHASE I Z� <br /> APPLICATION ACCEPT BY DATE <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 1426 4/72 1M <br /> i r <br />