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# Y <br /> SAN JOAQUIN LOCAL HEALTH bI;�TItICT <br />` FOR OFFICE USE: 601 E. Hazelton .Ave. j-=StUe'� c�i.,' Calif. <br /> Telephone:',,,(209)gU6 '6781 <br /> PLICATION FOR WELL ,CONSTRUCTION'OR PUMP PERMIT Permit No. 71 5 y 1 <br /> -THIS PERMIT EXP IRE S,1.�YEAR:IFROM,!DATl' ISSUED Date Issued �jr -y 7 Ii <br /> �'• Ry.(Complete In>Triplicate) <br /> Application is -herebyrmadelto the1`j5an,J6a4uintLocal 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 /> C unty Ordinance No:cc;1862.-a id,<the.*RulesbandF-Regulations"of= the. San Joaquin Local.-Health District. <br /> .,OB° ADDRESS/LOCATION _ � Q, n� _ CENSUS TRACT <br /> Owner's Narver ic ,.1, �' s'i Y �,xe.t a d c: ,':.., zx # Phone 3; <br /> Address a - 1 �..t �e_�.ttc City <br /> for s Nam �. . �__w� ... � _, .- _.•__�� ...-_—___.__� _ --- -- - <br /> Contract c�,v License 4W-00Phone ��1% <br /> V TYPE OF WORK (Check) : NEW WELL ( DEEPEN I / RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION 2/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOS 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 <br /> t Type of Pump ChL I <br /> (r H.P. <br /> PUMP REPLACEMENT:. / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done <br /> PESTRUG TION OF WELL: Well Diameter _P Approximate Depth I)O_. <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 /> WEL b TL RS REPORT oft'he-�e11 and notify them before putting t well in use. The above <br /> ' in orm do is true�toh+6 best of my kno 1 dge and belief. <br /> SIGNED t TITLE <br /> (DRAW OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION - PHA5 III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY E DATE <br /> CALL FOR A GROU INSPPCTION PRIG TO GROUTING AND FINAL INSPECTIO <br /> H 1426 4/72 <br />