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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FCR O FIC SE: l6Ci E. I'M7.01ton Ave. <br /> StoChtc,7; , Calif. <br /> `felt,plione: (2G9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OIt PiJ iP S'Eit111T Permit No.7"' ? <br /> THIS PERMIT EXPIRES 1 YHA , _,;;' T)ATE ISSkTED Date Issued <br /> (Complete In Triplicate] <br /> Application is hereby made to the San Joaquin Local ilealcti District for a permit to construct <br /> and/or install the wort: 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 /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT c ' <br /> Owner's Name <br /> Phone <br /> Address l <br /> City Lail <br /> Contractor's Name r <br /> License # 00_ Phone 2^9_847 <br /> TYPE OF WORK (Check) : NEW WE LL / % IDE ?FN, /_/ RECONDITION /_/ DESTRUCTION /? <br /> PUMPAL <br /> INSTALLATION /'-/- PUz,P REPAIR / / PUMP REPLACEMENT /7 <br /> Other Z'-/ — add COIL.-n to 9 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -Now <br /> trial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 0 <br /> Domestic/public Driven Gauge of Casing N <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 /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 ell, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well an notify them before putting the well in use. The above <br /> information is tru -,to the best o <br /> nowledge_ and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 7 �__� <br /> PHASE II GROUT INSPECTION PHASE SII/FINAL <br /> INSPECTION BY DATE INSPECTION <br /> INSPECTION BY DATE - ~� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> x+/72 IM <br />