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SAN <br /> L <br /> JOAQUIN LOCAL 11EiNLTI-1 DTS-11ICT <br /> FOR OFFICE USE: <br /> E. Haze.! toa AvQ, ' ­qtoc z Calif. <br /> Telephone: (209) 466--6/8.'11 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEJUMIT <br /> Permit No. 721- F 5 <br /> THIS PERMIT EXPIRES ,l YLARIFROM DATE :ISSUED Date Issued <br /> (Complete In <br /> F4 4nTriplicata) <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 <br /> 4CENSUS TRACT <br /> Owner. s�Name <br /> Phone <br /> Address <br /> '7 41 Ae- G 4 city LeAl <br /> Contractor's Name 4 <br /> — License <br /> Phone '4P7 <br /> -7 -7 <br /> TYPE OF WORK (Check) : NEW WELL �/X DEEPEN RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIRI PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _6 pr 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 S-e-a-1- p &OEM <br /> Other <br /> K Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. 2 <br /> PUMP REPLACEMENT: 5Y State Work bone <br /> PUMP REPAIR: State Work Done <br /> ;DESTRUCTION OF WELL: Well Diameter <br /> 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 A <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> 'LOT PLAN ON REVERSE SIDE) <br /> 64jdt'L�OT�p�LZ <br /> D <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY E 6172, <br /> ,ADDITIONAL COMMENTS: <br /> PHASE,y,P.T.-yGROUL_INSPECTION PHA INSPECTION <br /> INSPECTION BY DATE 9- INSPECTION BY 4MDATE t_ L7 <br /> CALL FOR <br /> T N PRIOR TO GRO TING AND FINAL <br /> INS- T <br /> E H 1426 4 <br /> 4/72 1M <br />