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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC SE' 1601 E. Hazelton Ave.', StocKton; Calif. <br /> Telephone': (209). 466'=6781 <br /> .. APPLICATION FOR WELL CONSTRUCTION }QR PUMP PERMIT Permit No. d <br /> R Date Issued 7 7oC <br /> THIS PERMIT EXPIRES 1 YE:SRFROF1 DATA. I� S� SUED �jQ ` <br /> (Comglete In Triplicate) ermit Co conr u t r <br /> Applicationpis hereby'-.made to .the San,JoaquTh Local Health District for •a p with <br /> and/or ,instal.l ,.the work herein described. This applonstofnthe San'JoaquinpLocal eHeal.thSDistrict. <br /> County +Ordinance No,: 1862 and- the Rules>and- Regulata A <br /> • r.:� s ,,, k . a. - �;•° G �I .S' l: CENSUS TRACT <br /> .JOB ADDRESS/LOCATION J7 d <br /> - A .Phone <br /> Owner.'s Name <br /> `4 i h:�: / <br /> T 8T City <br /> Address 17© - <br /> ,` �� D: ;Phone <br /> Contractor's Name . Y �' License ' r•. ! +, s.. '" <br /> 1► <br /> TYPE T OF WORK (Check) : NEW WELL 677 DEEPEN / RECONDITION / / DESTRUCTION /-7/_7 PUMP INSTALLATION /�►/ `:P TREPAIR / / PUMP <br /> Other J J. - - - - , <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER.LINES PIT PRIVY OTHER <br /> —""r-� CESSPOOL/SEEPAGE PTT <br /> t,�,SEWAGE DISPOSAL. FIELD _ <br /> T b1 ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Excavation (y <br /> ',Industrial Cable_Tool s.,; _ <br /> Drilled Dia. of Well Casing �� ` <br /> _ <br /> Domes tiFc1/pr iya-.te ; j Driven Gauge of Casing - <br /> Do04 <br /> mestic/public' = O <br /> Irrigation Gravel Pack �` Depth.`af._Grout Seal <br /> Rotary Type of Grout _.- C fir'`' ' <br /> Other . <br /> Other Other Information ' <br /> r �� <br /> r <br /> �F "T(! � <br /> A-V I P C rG <br /> s PUMP INSTALLATION: Contractor H.P. ' <br /> Type of Pump Z. <br /> PUMP REPLACEMENT: `State Work Done <br /> tiw ? <br /> I PUMP REPAIR: J / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply with all laws and regulations of the San. 3oaquin 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 <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 /> TITLE _ r/►-t it�'Lr� z''r — <br /> SIGNED <br /> � (BRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE . "" <br /> APPLICATION ACCEPTED BY <br /> r ADDITIONAL COMMENTS: PHASE IIID IN INSPECTION <br /> PHASE II GROUT INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY O�QDATE 5LZ3 r. <br /> -- --�� <br /> CALL_ FOR A GROUT INSPECTION PRIOR TO, GROUTING AND FINAL INSPECTION. <br /> s a /72 1M <br /> E H 1426 6�,(Q6 - '44/7 <br /> � �'"' <br />