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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,- S°tocktor:, Calif. <br /> Telephone: (20:9) 46&-6781 <br /> APPLICATION FOR WELL CONS`IRUCTION+°OR PUMP PERMIT Permit No. 7 2,. G r3 <br /> THIS PERMIT EXPIRES 1,YEARv`FRUM-DAT�;.,ISSUED Date' Issued - 7`/ <br /> (Complete' 1r ,Ti-,1,p1jta <br /> Application,':,i.t.hereby�:made sto tahe:,;San Joaquiw-Loea1, Uealth District;for a� permit -to construct <br /> and/or install the work herein described. This!�t,apptication i-s:made: in comp]:lance- with' San' Joaquin <br /> County::�Qrdinanee";No�=11862 ,,and,at3he°;Ru�IesA:,and>Regulatiotis,m6£ the,San Joaquin' Local Health District. <br /> JOB ADDRESS/LOCATION _ Aa loot a bid tnCO #4 CENSUS ,TRACT <br /> Owner'ac:?Name, .- *_ b : '' t w. �,: :., _ _ . Phone s <br /> Address 016 /1 irrn �ry-� <br /> City <br /> Contractor's Name es622 License # �fj-�yl�f'hone �G7-�67 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> .... .Other' ./ <br /> DISTANCE TO NEAREST:' - SEPTIC' TANK SEWER LINES PIT PRIVY <br /> $EWAGE; DI.$PO$AL,FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> f <br /> INTENDED-USE : TYPE OF WELL CONSTRUCTION':SPECIFICATIONS <br /> Industrial <br /> Cable Tool Diva. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge` of Casing <br /> Irrigation . ,Gravel Pack Depth; of; Grout Seal _ <br /> Other Rotary Type of Grout <br /> ' Other Others Inforination <br /> , <br /> PUMP INSTALLATION: Cy'n <br /> tractor <br /> Type <br /> cSgt,�J <br /> of Pump .XC, 4,l _. r _�. 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 Distric,'t <br /> and !the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> aftIr completion' ofmy work on a new well, I will furnish the San'Joaqu n Local Health District a <br /> WELD DRILLERS REPORT of the well andnotifythem before putting the well in use. The ,above <br /> . <br /> infgrmatzan is truetothe best of my knowled a an_)belief. : <br /> SIGI E CS <br /> ITL <br /> E <br /> D PLO PLAN ON RE RSE SIDE <br /> ., <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP—PTICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHAS , III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BXDATE <br /> BALL. FOR A GROUT LLIN PE TIQN.PRIOR TO GROUTING AND FINAL INSPE,CTION.,._ r <br /> ....E H 1426 � <br /> 4/72 1M <br />