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AN JOAQUIN LOCAL 111EALTH DISTRICT <br /> FOR OFFICE USE: �; V 1601 E. Hazelton-'Ave.,; -Stocktr,;-i, Calif. <br /> Tele:�hond: ,'.(209) ;466=-6751 r <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. 7�_'� � <br /> THIS PERMIT EXP�fRES AI ,YEAR 4'FROM DATE 'ISSUED Date Issued <br /> (Complete In Trip��icate) <br /> Appl icata ori kis:.he.reb.y: ade to,the.SanrJoagu n,;Laca1 1lealtih District fox a permit to construct <br /> and/or install the woxk .hereii, described. This application is made in compliance with San Joaquin <br /> Cotunty,_Ordinance:`No 51862 -anid%the Rulesiand: Regulations -of,'the ..San Joaquin Local Health District. , <br /> �✓g7 _:` �SE �..I + -[1..t9 �y ';. c <br /> JOS ADDRESS/LOCATION , , s .. ;. e ,.f, :. �toTH 7r► ,tie SOU IoxO'k � �?�'.CENSUS TRACT <br /> br, "stir -Y1 <br /> Owner'.s-Name ;. rp, .., 3:` _ Phone ' - f i <br /> i <br /> Address City ' <br /> Contractor's Name License # &o Phone F38-7 '7 y � <br /> TYPE OF WORK (Check) : NEW WELL /!�/, {DEEPEN / "/:.:PRECONDITION-=/��=-DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK a=- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE y 4 TYPE OF !WELL � CONSTRUCTION SPECIFICATIONS { <br /> Industrial X { Cable Tool Dia. of Well Excavation <br /> Domestic/private ' " D� illed ; Dia. of Well Casing 8mke2m � AAA5_ i <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation "1. Gravel Pack Depth of Grout Seal <br /> Other � ®g ;Rotary ; Type of Grout <br /> 4. 10ther FOther Information ' - <br /> PUMP INSTALLATION: Coritractori `1 0 <br /> - Type of Pump H.P. <br /> PUMP REPLACEMENT: / / Stat "Work Done <br /> ). , <br /> PUMP REPAIR: /1 /-State. Work Done,;, ,N <br /> F h � <br /> ,pESTRUCTION OF WELL: OWel.1..,Diameter:r ._T_ -"Y _---- -:�. -Approximate Depth. <br /> Describe: <br /> Material and Procedure <br /> I hereby agree to comply wi-thi4L11 laws and regulations of the San Joaquin Local Health District <br /> and the State of Cali.fornialpertaining° to or regulating well. construction. Within FIFTEEN DAYS <br /> after completion of my work on a nein well', I will f{.irnish 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 ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> P E II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE c =� INSPECTION BY O� DATE - 72- <br /> — <br /> INSPECTION <br /> FOR A_GROUT INSPECTION_,PRIOR„TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />