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FOR OFf,1CVUSE: `'SAN JOAQUIN LOCAL HEALT1,11 DISTRICT <br /> E. Haze-1-ton Ave. . <br /> Telephone: (209') 466---6/81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N.o. 7 Z-5 0 <br /> THIS ,.PERMIT E)[PIRES. 1 YEAR FRODATE, ILSSUED Date Issued- - 319- -7?--- <br /> 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 incompliance with San Joaquin `,! <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 71 <br /> JOB ADDRESS/LOCATION _,Ezc&_ r d DF -u 4, <br /> ----------------- CENSUS TRACT ' <br /> f. <br /> Owner's Name <br /> -e-r Phone ' <br /> i. <br /> Address _34 -7 City , <br /> Contractor's Name License # <br /> _7_M Phone <br /> U <br /> TYPE OF WORK (Check) : NEW WELL -7 <br /> . .0 DEEPEN 1_7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION KI PUMP REPAIR REPLACEMENT— /_7 <br /> Other <br /> DISTANCE TO NEARESTi SEPTIC TANK SEWER LINES <br /> -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> cr <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven _4 Gauge of'Casiiig <br /> —.,Irfigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout <br /> OtherOther Information ',ge> <br /> ,v <br /> r. <br /> PUMP INSTALLATION: Contractor <br /> Type of 4 Pump -eu A-- H.P. <br /> C> <br /> PUMP REPLACEMENT: /_7 state work Done <br /> PUMP REPAIR: 'Stdte..Work Done <br />.PESTRUCTION 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 <br /> my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well+andlnotify them before putting the well in use. The above <br /> �tu <br /> inform t, "eat e best of my knowledge and belief. <br /> SIGNED 6AQ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE'ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED <br /> 3,a V_ .-I az&lel DATE <br /> r��?� <br /> ADDITIONAL COi4�99TS; f_. <br /> PHASE II GROUT INSPECTION 1 4 PHASE III jFI3ALINSPECT ON <br /> INSPECTIOX�BY7_ DATE INSPECTION-BY )!Ke� DATE <br /> CALL: FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION., <br /> E H 1426 <br /> 4172 1M <br />