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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave: , Stocktor, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-72-40 ?� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued&J <br /> (Complete In Triplicate) <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 application is made in compliance with San Joaquin <br /> County Ordinance No. -1862 and the Rules and Regulations .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6A/ A Y4- CENSUS TRACT <br /> Owner's Name + # Phone &17k- e 9'�l <br /> Address 6�f�s L-��1�/�� _ _Vl-" City S' / 0C/ 7-0 <br /> Contractor's Name _� �� j -��j�/�"�L x f ��/1� [' (t z License # �66a Z Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / - 4 G'C/ _p 13i& ! 0 O / L 7- <br /> DISTANCE <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 <br /> Industrial Cable Tool Dia. of Well Excavation _ z a Q' ' <br /> Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven Gauge 6—V a of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal (J .� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor a762 we,4 <br /> Type of Pump V -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter 1 Approximate Depth o0o <br /> Describe Material and Procedure L/) z „ Q if(I _7_�..___. <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 best of my knowledge and belief. <br /> SIGNED _ I �., .._. TITLE 60 Al7'IP14 6/ell'P <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> C .FOR DEPARTMENT USE ONLY <br /> PHASE I ,�t� <br /> APPLICATION ACCEPTED BY - "(�flr-�J.,........,,,.. __..._,..,._._�.. . ._.__— DATE -- w� - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F AL 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 <br />