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) SAN JOAQUIT% LOCAL HEALTH DISTRICT <br /> F40R OFFICE USE: 1601 E. Hazelton Ave. , Stocktot, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L�C3 <br /> THIS PERMIT EXPIRES, 1 YEAV, FROM DATE TSSUED Date Issued <br /> (Complete` In Triplt ate) <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 .p� /3_. -g����- ��riyr�-a CENSUS TRACT <br /> Owner's Name J y ,r����� ��' Phone �O <br /> Address r City c <br /> Contractor's.Name Id42-E License 4t0�� Phone 4��— A <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_-T RECONDITION /-7DESTRUCTION /-7AL <br /> PUMP INSTLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other I / <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 2. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauggof Casing <br /> Irrigation Gravel Pack Depth of Grout Seal If <br /> Other Rotary Type of Grout m-Fy-z ' <br /> Other Other Information <br /> t <br /> i <br /> PUMP INSTALLATION: Contractor O O-G sa <br /> Type of Pump H.P. .. <br /> PUMP REPLACEMENT: / / State Work 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 O <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 o e well and notify them before putting the well in use. The above <br /> information is trueto the my knowle ge and belief. <br /> SIGNED TITLE C <br /> DRAW PLPT PLAN ON REVERSE SID <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> 'APPLICATION ACCEPTED DY(att DATE / L-- <br /> 1ITIONAL COMMENTS. <br /> PHASE II GROUT„INSPECTION PHASE III FINAL INSPECTION <br /> ON BY Ei{ DATE -K- INSPECTION BY DATE , <br /> A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 6 4/72 <br />