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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel toii'Ave:; 'St.oekton, Calif. <br /> Telephone: (20.9) t,4G61L-6781 <br /> P KATION FOR WELL CONSTRUCTION-",,'OR PUMP PERMIT Permit No. Z.2-6 �} <br /> s T IS PERMIT"-EXPIRES--.l:YEAR`;FROM-:,DA:iE .ISSVED Date"Issue, <br /> -(Complete In Trip]iicate) '; , <br /> Applicatiron',,. here ,,made:t- ;they San' Joaquin-.Local Health Dz'str-ictL f'or a:perrrfi't-to' construct <br /> and/or install the work herein described. -This}application�is5made-inicompl,.iance .with- San,'Joaquin <br /> County-,Ordinance,^No 1862­and�,theiRules,and-Regula-tions .of :the, San'Joaquin,Loc.al. 'Health. District. <br /> x".` <br /> JOB ADDRESS/LOCATION <br /> -a� :,s:• �� �[ � E - �Y CENSUS TRACT':z Sof, <br /> Owner S iNaae.� , <br /> . t( Phone + JF in <br /> AddressCitl <br /> Y <br /> Contractor's Name <br /> L:icense # /nZA-�Phone <br /> TYPE OF WORK (Check): NEW WELL / EEPEN /%„RECONDITION /7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR J /^'PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 7 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p� <br /> INTENDED' USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Lam--Gable Tool Dia, of Well Excavation 4,4� <br /> omestic/private Drilled Dia, of Well Casing tj <br /> Domestic/public ' Driven' Gauge of. Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout — <br /> I Other Other Information <br /> k PUMP INSTALLATION: Contractor 1c�/ <br /> Type of Pump H.P.. <br /> f- <br /> r _ <br /> PUMP REPLACEMENT: / / State Mork Done <br /> PUMP REPAIR: /% State Work Done <br /> ,DESTRUCTION OF WELL:. Well Diameter Approximate Depth <br /> Describe Material 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 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 true to the be'st. of my knowledge and belief. <br /> SIGNED. L _ TITLE. d <br /> (DRAW PLOT PLAN ON REVERSE SIDE)-- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f '� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION _. <br /> INSPECTION BY DATE �� -7 Y INSPECTION BY DATE Jb -3-7Z- <br /> CALL <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . _ 4/72 1M -' <br />