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SAN JO�'Q IN LOCAL '117ALT" �TSTRICT <br /> r'OR OFFICE USE: 1.601 E. Har . Ston Ave. , Stoc tn,:,, <br /> Calif. <br /> Telc:)hone : (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP P RMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM' DA'; <br /> (Complete In <br /> __-f_ Date Issued <br /> Triplicate) V-:�_ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work 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 ti,Lf r; <br /> Owner's Name er <br /> Phone w � <br /> Address <br /> 15294 T- n� Ha <br /> Contractor'sName <br /> r-z- .city <br /> r _ _ License # 2- inn Phone <br /> i9.R L7i <br /> TYPE OF WORK (Check) : NEW WELL / / DIL?EN_/ / RECOND'TION /_/ DESTRUCLIOi�m , � <br /> / <br /> PUMP INSTALLATION /�/ PU1'.q" REPAIR /—/—PUMP <br /> _/ PUMP REPLACEMENT /_7 <br /> Other / / Ghech OLMID ---- repair a.f recess�r- <br /> DIST,LNCE TO NEAREST: SEPTIC TI;:%k ``ER `-- <br /> SEWLIiV.,s i'I.T PRIVY <br /> SEWAGE DISPOSAL, i'xELD !'FS GOL/SEEPAGE PIT <br /> ------- OTHER <br /> INTENDED USE TYPE OF WELL <br /> Indu l_" ------ GOiSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> 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. rr <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 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 tr -.to the best of my kn led e and belief. <br /> SIGNED , <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. DATE <br /> E H 1426 <br /> 4/72 1M <br />