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SAN JOAQUIN LOCAL HEALTH DISTRICT SCD <br /> _. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockto•.x, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72- <br /> THIS <br /> 2- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' ? 7i <br /> (Complete In Triplicate) <br /> Application il hereby made to the San Joaquin Local Health District for aP ermit 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 CENSUS TRACT <br /> Owner's Name ,�Ju1a Phone <br /> Address _ 74 6h-.,;h, - &urs <br /> City �F-,�,�L �'�.�... <br /> Contractor's Name �i P License # 116 Phone <br /> TYPE OF WORK (Check): NEW WELL/% DEEPEN -/T RECONDITION /-T DESTRUCTION /"T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other /-7 <br /> — — — <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial --y 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 /> i <br /> Type of Pump 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 ,, (O,S",)TITLE �� <br /> �DAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I )/G� /J L <br /> APPLICATION ACCEPTED BY (�� � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASF, II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY r- F�i <br /> DATE INSPECTION BY 0 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M Com` <br />