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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: C 601 E. Hazelton Ave. , Stocktor Calif. <br /> Telephone: (204) 466-6781 <br /> o <br /> APPLICATION' FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7- q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Tri <br /> (Complete In Triplicate) <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 OU Ac CENSUS TRACT <br /> Owner's Name � ► _ �v'g t� Phone 'y! ."'♦00 :: <br /> Address City , <br /> Contractor's Name _A4acolft # Phone <br /> TYPE OF WORK (Check) : NEW WELL At DEEPEN / / RECONDITION /7 DESTRUCTION /7 - - - <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well.Excavation V <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal o' <br /> Other Rotary Type of Grout <br /> Other Other Informatio f <br /> PUMP INSTALLATION: Contractor ?Mzor' 4 -Q <br /> Type of Pump Jr H.P. <br /> PUMP REPLACEMENT: / / State-Work Done <br /> PUMP REPAIR: / / State Xork Done <br /> DESTRUCTION OF WELL: Wel 1. Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all l Aws andulat ons -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 and notify them before putting the well in use. T e above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAT) PLOT PLAN ON REVERSE SIDE)- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE aJ� <br /> ADDITIONAL COMMENTS: <br /> P UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - - z/ INSPECTION BY DATE <br /> � CALL FORA INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ETH 1426 4/72 1M <br />