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SAN JOAV' IN LOCAL HEALTI-1 DISTRICT <br /> FOR OFFICE USE: 1601 "E". Hatelton Ave. , Stoct:to-, Calif. <br /> Telephone:p (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE)i SSUED , Date Issued <br /> (Complete In Triplicate) <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 with San Joaquin l <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �C' J S, l i,�o L i,'z� CENSUS TRACT <br /> r <br /> Owner's Name `�i7��ru��-� �7zecL��eu Phone ��`g'2-q qS- <br /> Address J 7 �6' �- _ lu"3,za �.(�c�-� City <br /> Contractor's Name,jl�er;vrFr� ..l License # // 31;� Phone �7 <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/_/ RECONDITION /-7 DESTRUCTION /-7 + ' <br /> PUMP INSTALLATION /—/ PUMP REPAIR/-7 PUMP REPLACEMENT /-7 <br /> Other / / <br /> \l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ------ r <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT — OTHER o <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS jq <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 v' _ <br /> Other Rotary Type of Grout :�,9... <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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 � TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: —� <br /> PHASE II,GX0"SIECZON PHASE F AL INSPECTION <br /> INSPECTION BY /DATE INSPECTION BY ,,,_ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 I,2;d z0. ohre 4/72 1M <br />