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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stocictoa,; Calif. <br /> Telephone: (209) -466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR `FROM DATE—ISSUED Date Issued /7� <br /> (Complete In Triplicate) F g? <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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> e!:O 0 <br /> JOB ADDRESS/LOCATIONQ CENSUS TRACT , <br /> e7 t'a. <br /> Owner's Name . "' ,7; Phone ' <br /> Address ! <br /> city <br /> Contractor's Name r C'(U, License # <br /> &64 Phone Ylz <br /> TYPE OF WORK, (Check) : NEW WELL.;/-7 DEEPEN '/_/ RECONDITION DESTRUCTION / <br /> PUMP INSTALLATION '/ / PUMP_REPAIR / / PUMP REPLACEMENT <br /> Other / / /? <br /> -1 <br /> DISTANCE TO NEAREST: SEPTIC TANI( SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERr <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of: well.-Excavation <br /> Domestic/private Drilled Dia. of We11 Casing i ji <br /> DUmes�tic/publi:c r - Driven <br /> Gauge of Casing <br /> Irrigation 'Gravel Pack Depth of Grout Seal � Q <br /> Other ' ' , Rotary Type of Grout <br /> Other Other Information' j <br /> ' yJ �-•'— � � f <br /> E <br /> PUMP INSTALLATION: Contractor .� . <br /> Type of+Pump <br /> _ H.P. <br /> PUMP REPLACEMENT': t <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br />.DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 /> informatio. tr a to the best of my knowledge and belief. <br /> m. <br /> SIGNED - <br /> -;OL-TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) � <br />!'RASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> i k< <br /> ADDITIONAL COMMENTS DATE <br /> PHASE II GROUT INSPECTION P II/ INAL INSPECTION <br /> INSPECTION BY DATE 2�t�-�7 2�... INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />