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SACT JOAQUIN LOCAL, IIE!1I,TxI ;DISTRICT <br /> FOR OFFICE USE: 1601j� !'. Ha-,;� _ton Ave. , Stoc. --o� ; Calif. <br /> TelUphone {201 } 466-6781- <br /> PLICATION FOR WELL CONSTREJCTION OR I'U1u' PERi:iT Permit No. <br /> A 12 <br /> Tj THIS PERMIT "EXPIRES l YEAR Fitt/ D.,^..TT-S IUED Date Issued <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 a d Regulations of the ,San Joaqu;n Local Health District. <br /> JOB ADDRESS/LOCATION WAW o Asa/f-. 04 h h*0 CENSUS TRACT <br /> Owner's Name 1`3Phone <br /> Address (41 f y1GCn'C City M*4t746GOC, <br /> Contractor's Name License #;$3 o Phone 6 6 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR jF�UMP REPLACEMENT /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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 5 <br /> Irrigation /' Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done a as I SIJ!ttJ1r i'1 <br /> .RESTRUCTION 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 m knowle and belief. <br /> LE <br /> ,4w.// <br /> SIGNED cC <br /> ( PLOT PLAN ON RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� ' DATE `r <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III ' NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION DATE Z Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />