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SAN JOAQUIN LOCA. HgALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. ,' Stockta_, Calif. <br /> Telephone: (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued;-9, 2_?- -7,,,? i <br /> (Complete In Triplicate) <br /> f 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 Rul s nd9uldtions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �/ CENSUS TRACT <br /> zt <br /> Owner'sName - Phone ` <br /> 1Ap�ew�_-lir'---- City <br /> Address <br /> Contractor's Name I License Phone <br />' TYPE OF WORK (Check) : , tNEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTLATION PUNK' REPAIR J J PUMP REPLACEMENT /7 <br /> ALM <br /> Other j J <br /> } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD +CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ', CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia, of Well Excavation /p <br /> Domestic/private;; Drilled Dia.. of Well Casing <br /> _ Domestic/public �� Driven Gauge of Casing <br /> Irrigation I; Gravel_Pack-._ _''Depth of Grout Seal <br /> Other ': Rotary Type of Grout ) <br /> Other i Other Information <br /> F PUMP INSTALLATION: Contractor - I' <br /> Type of Pump H.P. =MOW <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 mywork on a new well, I will :furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them•beforexputting the well in use. The above <br /> information is true to the best-,of my knowledge and belief. t <br /> y � TITLE (- <br /> SIGNED -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,I FOR DEPARTMENT USE ONL " <br /> PHASE I a ` <br /> .APPLICATION ACCEPTED BY DATE - "�� <br /> � . ADDITIONAL COMMENTS: 'I w <br /> PHASE II�GROUT..INSPECTION--'- -,n--4 -- - - ;;,. - •-PHASE-II-I-/-FINAL-INSl?ECTION <br /> INSPECTION"BY DATE 4 INSPECTION-BY(' DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO 'GROUTING AND FINAL INSPECTION. ry <br /> k <br /> E H 1'/26 . fir. ,� 4/72 1M , <br />