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- SAN JOAQUIN LOCAL HEALTI'' DISTRICT <br /> OR OFFICE USE: 1.601 E. Hazelton Ave. {StocktoL, Calif. t <br /> Telephone: (209)_:466�r'-.6781- <br /> PLICATION FOR WELL CONSTRUCTION,OR PUMP PERMIT Permit No. <br /> i e/ <br /> THIS PERMIT -EXPIRES. I,.YEAR•:.FROM-.DA�.E,4iSSUED;�--.: Date Issued,_ , <br /> .r. (Complete In Trdplicate) � . p <br /> Application isohereby madewto. .the San<° Toaqu hispaal]icationo construct <br /> is�made�in�cn pl.ianee,.with: San,Joaquin <br /> and/or install the work herein described. pp <br /> County.rOrdinance�No:c1862randi,:the_.Rules n <br /> and,;Regulavwons.:ofUthe.San-Joaqui :Local'-Heal th'Distr^ict. <br /> u- } .tA <br /> �� CENSUS TRACT <br /> JOB ADDRESS/LOCATION as 777777777. <br /> juix <br /> owner's::Name <br /> City <br /> Address 4-4 <br /> F a � -... <br /> Gn License # 2 71 f�[1L1 Phoned.24= o <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR'/ _ <br /> / PUMP REPLACEMENT IST <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER C <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial <br /> X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ------ (1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t' <br /> Other Rotary Type of Grout <br /> Otherr Other Information <br /> PUMP INSTALLATION: Contractor S Joaquin Ptml C° '� 1nc <br /> Type of Pump Tuxb'ne H.P. ^75 <br /> PUMP REPLACEMENT: / / ; State Work Done <br /> k <br /> PUMP REPAIR: / / State Work Done <br /> iApproximate Depth <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> k Describe Material and Procedure <br /> cal <br /> lth <br /> rict <br /> t I hereby agree to comply with.all laws fipdo elations awelleSan Joaquin c.onstruction.LoWithinaFIFTEENtDAYS <br /> and �the State of California pertaining regulating <br /> E 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 belie <br /> ITLE <br /> SIGNED <br /> (DRA LOT LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY �7 <br /> PHASE I DATE {7'f " �� - <br /> APPLICATION ACCEPTED B_Y <br /> ADDITIONAL COMMENTS: PHASE II/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION � INSPECTION BY DATE . <br /> INSPECTION BY DATE <br /> CALL F'OR .A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.., <br /> . .M.- v 4/72 iM <br /> E'H 1426 <br />