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t <br /> O SAN JOAQUIN LOCAL HEALTH DISTRICT. r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockto.q, Calif. <br /> Telephone: (209) 466-6781 If"' <br /> APPLICATION'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. —J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED- Date Issued <br /> (Complete In Triplicate) ��I r Ito-os <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 /> 1-- - <br /> 1 JO$�_6131D <br /> E�ADDRESS/LOCATION ..��, e - <br /> ` ' tez, CENSUS TRACT <br /> Owner's Name % <br /> a Phone _ <br /> Address 01 <br /> ow 44 n Y ;�£✓ - _ i <br /> - ,Cit <br /> Contractor's Name License # IL Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_/ RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other PUMP REPLACEMENT /_7 <br /> / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> 1 <br /> INTENDED USE _TYPE OF WELT, . f <br /> _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing , . <br /> Domestic/public t Driven Gauge of, Casing <br /> Irrigation Gravel Pack Depth of, Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. + <br /> PUMP REPLACEMENT: / / State Work Done <br /> E <br /> S tateWork .Done ... - ,� —- . _ . _ -... 1 <br /> za <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 /> SIGNEDti u p TITLE : _ <br /> (DRAW PLOT MAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION, ACCEPTED BY <br /> DATE SP <br /> ADDITIONAL COMMENTS: i <br /> PHASE II 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 /> E H 14.26 4/72 1M <br />