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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE IJSE: 1601 E. Hazelton'Ave., :Stoc«ton, Calif. <br /> Telephone:. (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7i- 7 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued2 z f- 2 Z <br /> (Complete In Triplicate) <br /> Application is hereby ma a to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereindescribed. 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 f ,,� CENSUS TRACT <br /> Owner's Name 1 6L 0.0 6, •tr Phone <br /> Address City #,K � <br /> Contractor's Name License /rta 22,f'Phone $Ag 3- ?L74,' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION /—/ —PUMP REPAIR Y/ PUMP REPLACEMENT /- <br /> Other /-7 <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 <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 Other Information <br /> PUMP INSTALLATION: Contractor w& <:) <br /> Type of Pump ti r xg1A H.P. yTo <br /> PUMP REPLACEMENT: / j State Work Done <br /> � 1 <br /> PUMP REPAIR: J C/ State Work Done ,r ,.��,,� r� w � p x.40 f <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 best -of my knowledge and belief. <br /> 6 r. <br /> ��. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSES E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Se DATE n <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ' III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M G1 <br />