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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 16CAIL E. R-zelton Ave -Stoci(t-.or , Cal--I:.f <br /> Tel,iphoae: (209),--,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUl�T PERMIT Permit No. <br /> THIS PERMIT EXXIRES 1.YEAR ITOM D2,�TTZ I.SSUEDi Date Issued- <br /> (Complete In Triplicate) <br /> Application.1s, herebymade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. Thi's application is made in compliance with Sari Joaquin <br /> County Ordinance No. .1862 and,,the-Rules and Regulations �of the San Joaquin Local Health District. <br /> T ' <br /> JOB ADDRESS/LOCATION A CENSUS TRACT <br /> q <br /> V, Phone <br /> Owner's Name;` <br /> Address .City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELLI DEEPEN RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR -'/ PUMP REPLACEMENT /-T <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELDCESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing V1 <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 _23 <br /> Type of Pump' H.P. <br /> PUMP. REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> .PESTRUCTION OF WELL: Well Diameter "Appioximate 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, Itwill 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 true to the best of my knowledge and belief. <br /> SIGNED Z--- TITLE <br /> 4V (DRAW PLOT PLAN ON REVERSE SIDE)___ ,__ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE —5 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COM11ENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE E INSPECTION BY --DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 314 <br />