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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockto: , Calif. <br /> .. Telephone:- (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION.OR PUMP PERMIT Permit No. ;? � �I <br /> �- HIS PERMIT•EXPIRES .l YEAR FROM DATE'ISSUED Date Issued ;To ,7T/ <br /> (Complete 'In•Triplicate) <br /> Application is hereby. made o .the San: Joaquin 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 /> C944ty Ordinance. N-o. 186_2 and the Rules and Regulations :of She San Joaquin Local Health District. <br /> SSJ<L.00ATION7 - CENSUS :TRACT I <br /> Owner's Name '�..: . `]_ _j \1'L - _ - Phone -U <br /> Address c - C �EC� '� City r/-Q <br /> Contractor's Name ! J _ icense_�6 1,L4phone � <br /> TYPE OF WORK (Check): NEW WELL "/ / DEEPEN /7 " RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR -/ 7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> Industrial ; Cable Tool Dia. of Well Excavation ' 0 <br /> Domestic/private / Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal i- <br /> Other- - T-Rotary - ""TypeYof"Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �1 <br /> Type 'of Pump H.P. <br />---�-PUMP:REPLACEMENT: -State Work,Done� <br />� - PUMP REPAIR: / / State Work Done i <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 /> I WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is ruefto the best of 'y knowledge and belief. <br /> SIGNED �v. ` TITLE <br /> / / (DRAW PLOT PLAN-ON-REVERS1 SID <br /> I FOR DEPARTMENT SE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEEII 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 /> 1 E H 1426 w 4/72 1M <br />