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SAN JOAQUIN LOCAL HEALTH ,DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocictua, Calif. AK <br /> / e-o Telephone: (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7S- 3 1 16) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued_ -S r 7x `s <br /> (Complete In Triplicate) <br /> Application is h re y 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 with 'San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION gr JOS/ y1e� CENSUS TRACT " <br /> Owner's Name /s r Ma n 0004 Phone <br /> Address b 4�m.�r city �hr, <br /> Contractor's Name License #/ Phone 1!`6i 5.�. <br /> TYPE OF WORK (Check) : NEW WELL �-� DEEPEN RECONDITION RECONDITION/-7 DESTRUCTION /-7PUMP INSTILLATION /—/ PUMP REPAIR I / PUMP REPLACEMENT /-7 - , <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation! <br /> Domestic/private Drilled Dia, of Well Casing /y <br /> Domestic/public Driven Gauge of Casing �p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ti <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor emgg 4•So <br /> Type of Pump _ j < -5'4g & H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 my knowledge and belief. <br /> SIGNED ::A�Alan W TITLEe v i e r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY J�j Z . d � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASF,F. II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -i _ DTE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />