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SAN JOAQUIN LOCAL HEAL77 DISTRICT ".�— { <br /> A., OFFICIE USE:' r f. 1601 E. Hazelton Ave. ,. .Stocktoa,, Calif. <br /> Telephone:`: '(209)' 4661.6781 r <br /> APPLICATION/FOR'WEL-L 'CONSTRUCTION:'OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED - Date Issued -14 7 2- <br /> (Complete In Triplicate) . <br /> I Application.iisfhereby madeito the:,San..J oaquin Local .Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1.862 'and the- Rules' and ,Regulations of -the San.Joaquin' Local Health District. <br /> JOB ADDRESS/LOCATION) ., ..CENSUS TRACT- . <br /> Owner's Name ?, -, �` - � � Phone <br /> Address 5 � .�.•_ City <br /> Contractor's Name License # .4one AZZ <br /> TYPE OF WORK (Check) : NEW [,FELL '/ ./ DEE;k / RECONDITION /_7 DESTRUCTION /_7AL <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE SP EPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled D.ia. of Well Casing <br /> Domestic/public Driven . t Gauge of Casing <br /> tA <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> ,.` • G'tYier Rotary., Type of Grout <br /> p Other Other Information ' ' <br /> PUMP INSTALLATION t Contractor <br /> t' Type of Pump _ -rc.�a.,y mr'l+e jo H.P. )r <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: State Work 'Done <br /> ,DESTRUCTION OF -WELL:-'; Well Diameter _ Approximate Depth <br /> Describe Materiiil 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 -= 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 �t <br /> information true to the best of my knowle ge an ief. <br /> 000, <br /> SIGNED ITLE � w _ <br /> (DR= PLOT PLAN ON RE SE SIDE) <br /> FOR..DEPARTMENT USI ONLY Z <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f , DATE <br /> CALL <br /> FOR A GROUT INSPECTION PRIOR.-TO -GROUTING .AND FINAL, INSPECTION. <br /> ., . yFI,1426 4/72 1M <br /> 4 � y <br />