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r SAN JOA;QUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: C* 1601 E. °Hazelton:>A.ve. Stockron, Calif. <br /> I Telephone:-'.. (209)';--1466L6781 <br /> f APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. <br /> C THIS -PERMIT EXPIRES 1-YEAR,'FROM DATE ISSUED Date Issued /- Ili' <br /> j.. (C'ompl'ete ,In.-Triplicate-) ' <br /> Application' is- hereby�made�to the -San,rJoaquin.Loca1 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-land•,Regulations �of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' ��{]p '/V/ v 6,�� CENSUS TRACT ' <br /> :Owner's Name ,£ 7—R r- f tw �." !J `4'� Phone. 7 G 2 <br /> Address �� y�,(�� _ _ '1 c$"c _ =City.or <br /> cSza. �r . <br /> Contractor's Name z-0. License # 19:R Fkj"Thone I-- -4 <br /> ' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION.-/�. _/�7- PUMP- REPAIR': / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE " t TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool. fDia. 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 iOther Information <br /> PUMP INSTALLATION: ContractorIF <br /> - Type of Pump �'�u-r r`t� --- - . H.P. / O <br /> PUMP REPLACEMENT: J / State-Work Done 07 ;,A �- ' <br /> ' /j, .dEp <br /> PUMP REPAIR: / / State Work Done <br /> p_ESTRUCTION 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 /> F 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 k4/6 ge and belief. <br /> SIGNE / �~ <br /> TITLE <br /> DRAW PLOT PLAN ON EVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION...BY, M M. DATE INSPECTION BY DATE <br /> CALL FORA GR0 T ,INSPECTION .PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> t <br />