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{� SAN JOAQUIN LOCAL I3EALTH DISTRICT + <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.., 'Stocktor, Calif. <br /> Telephone: (2'09) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3 p O <br /> THIS 'PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED: <br /> Date Issued 1373 <br /> (Compete In Triplicate) Y0, '/- 3&o-!j <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 Lac 1 Health District. <br /> JOB ADDRESS/LOCATION <br /> ,�Yj..��/� CENS S 'TRACT <br /> Owner's Name <br /> Phone - <br /> 42; <br /> hone t� <br /> Address <br /> City <br /> Contractor's Name � � .I,���, � � •��,� License # f7. • � _ <br /> v / � Phone �f" <br /> TYPE OF WORK (Check) : NEW WELL / /: DEEPEN '/_/ . RECONDITION /`% DESTRUCTION /_7 - <br /> 7 "PUMP TNSTALI;ATTON PUMP: REPAIR'=/ '/ PUMP'REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PTT PRIVY 4' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> 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- Y Type of Grout <br /> Other Other Information <br /> - <br /> PUMP INSTALLATION: <br /> - <br /> � Co <br /> d_&_I fU' 4r ` TYPe of Pump er .-r <br /> PUMP REPLACEMENT: L /•.Mate Work Done <br /> PUMP REPAIR: /-7 State WorkDone - <br /> ,DESTRUCTION -OF WELL:---.Well Diameter- <br /> Approximate Approximate Depth <br /> D . _ <br /> escribe,Material and. Proeedure% - <br /> I hereby agree to comply with all laws and regulati6iis. afAthe' San J quiif-Local Health District <br /> and the State of California pertaining to or regulating.well construction: <br /> AYS <br /> after completion of my work on a new well, Twill furnish%the -s ' 'Joaquin LocalhHeaitin hTDistrict a � <br /> WELL DRILLERS REPORT of the well and•.notify�them before,�putting the well in use. The above <br /> k ,... <br /> information is true to the best of my knowledge and belief. <br /> f t -4 <br /> SIGNED; <br /> (DRAW <br /> TITLE PLOT PLAN ON � /f�r- /� # <br /> REVERSE SIDE) <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �j 7 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE ITGROUT INSPECTION A' <br /> INSPECTION BY PHASE I I/FINAL INSPECTION <br /> DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINALINSPECTION. <br /> E H 1426 <br /> 4/72 1M <br />