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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI E SE: 1601 E. Hazel ton'.Av&:'�Stocktbri, Calif. <br /> Telephone:,..'f(209),,466'=6781 a <br /> APPLICAT ION FOR WELL-CONS TRUCTION,OR PUMP PERMIT Permit No. <br /> �y THIS PERMIT•.EXPIRES>�1iYEAR-iF'ROM DATE` ISSUED . Date Issued 3-r f <br /> Compl-ete Iii­�Triplimcate) .. - . <br /> Application"€is;herebyimadeito the PSangJoaquin''Local health District`for. a permit to construct t <br /> and/or install the work herein described. This..application .is made=in compliance with San Joaquin <br /> County Ordinance allo._:7_S62sand:&the -of� the. San Joaquin Local Health "District <br /> C f ,U. �' v��. ; r11"U;Z__a )n r- �-�a lv�� ZtEO-c7S <br /> JOB ADDRESS/LOCATION �ors�r;r� e �wrm�-� o�Qa r CENSUS TRACT' <br /> �i.' y�°* ;y- rem �-,_� .."] ..'.�': <br /> Owners Name t .` rAawo��;44?,Fa llIC)t br'; fin 4 W:�� Phone - <br /> City ' <br /> hone "City <br /> Contractor's Nam ,.�- License # 1�3�g. -Phone ' a2,--79 Z� <br /> TYPE OF WORKCheck) :`7 NEW'WELV / / , DEEPEN _ _ - <br /> { � _ PUM <br /> / / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION`/ J _77 €'sREPAIR � PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST:- -SEPTIC TANK SEWER LINES PIT PRIVY �`a-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION+SPECIFICATIONS <br /> Industrial. ..... Cable Tool Dia. 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 t <br /> Other Rotary Type of Grout <br /> Other ""w Other ormation <br /> PUMP INSTALLATION: Contractor " ' ' <br /> Type of Pump + <br /> 7717 <br /> H.P.joV <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP REPAIR: State Work Done I I ,� a� _ e.. = <br /> e <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth f <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 workmon 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 thebestof my knowledge and belief. <br /> SIGNED" <br /> ITLEB . <br /> (D WS <br /> OT AN ON RE SE SIDE) <br /> PHASE I <br /> ���,l OR DEPARTMENT USE ONLY <br /> V 'S �. <br /> APPLICATION ACCEPTED BY .) D E <br /> ADDITIONAL COMMENTS: ccml <br /> NGRSUT <br /> II GROUT INSPECTION PHAS f INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A _INSPECTION PRIOR TO GROUTING AND FINAL INSP C <br /> E H 1426 4/72 1M <br />