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IN <br /> k. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :FICE USE: 1601 E. Hazelton Av..e. , 'Stockto-c , Calif. <br /> Telephone: (209) 466;-678 . <br /> APPLICATION FOR WELL CONS`i'RUCTION�AOR PUMP PERMIT Permit No. <br /> THIS PERMIT.EXPIRES- 1 YEAR'FROM..-DATE 'ISSUED:.;.,;' e.Date' Issued ' <br /> (Complete Irt:•Tripl'ieate:) <br /> > : <br /> Applications:isvhere_by�made-ito :theoSan ;Joaq i.nr.Local Health District`fbrra„petmi,t to construct ` <br /> and/or install the work herein described. This..application-„is:made-.in='compliance,'•with San ,Joaquin <br /> CountyjOrdinanceoNo g1862.'rand-�th6,iRules' and=rRegulations Jof the,San-'Joaquin Local: Health. District. <br /> rl __ -rte-:--r-...,” <br /> r+ .c o r :�g°'mi 'r`sout ro €Peltier Rd�� :_ mi.,.`eas ` of ''Dustin Rd`:x ,9 " <br /> JOB ADDRESS/LOCATION 4 .CENSUS, TRACT <br /> iI1Sl.i,t ;br :. VAa, <br /> n �.. t Y Phone' :. <br /> Owner sw�Nam��.. ?o r.s���.ors a Par 'f�e`�yA�aFA �` R � ` r '°fir` nyi <br /> a rm5" 1s4�q:R.�.�er—a d. �.�.— <br /> Address City. _.. <br /> 0 <br /> Contractor's Name n, C License # 971 Ann Phone ' Z�a_s�a7i _... <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / J RECONDITION /�/ DESTRUCTION /_7 <br /> PUMP INSTLATION/ / PUMP REPAIR I I PUMP REPLACEMENT I� <br /> AL <br /> Other. / / Deliver to Well site-.*' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> INTENDED 'USE - r TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <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 /> E I hereby agree to comply. with all laws and regulations of the San Joaquin Local Health District <br /> i 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 /> WELT; DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is rue to the best of knowledge and belief. <br /> i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I d <br /> APPLICATION ACCEPTED BY DATE 7-10'7.3, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _^ - .�_ DATE 11 a -��►�' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E.H 1426' ., - --- _. ._ <br /> _ .. .. _ a. - . . - ,4/72 1M <br />