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SAN JOAQUIN LOCAL HrALTH DISTRICT <br /> FOR,•OFFICE USE: 1601 E. Hazel ton,,'Ave. ;',Sfgcktou, Calif. -- <br /> Telephone:.,::(2©9),1466"6751 <br /> APPLICATION FOR WELL CONSTRUCTIONi'OR .P•UMP PERMIT Permit No. Z g 7 <br /> THIS PERMIT' EXPIRES .l;=VEAkdFROM-:DATE-ISSUEDb ,A k•-Date'-TIssued -/ : ?yr <br /> "ell ,`{Complete rn` Trxpl�:c;ate} <br /> Applicatioziiris ,hereby:.made--�•to thecSanrJoaquir�xLodal Healzth Dzstx ct s'for"a -permitf to,-Construct <br /> and/or install; :the work herein described. This Fapplication`.isr'madeairi'"coripl ance-:writh=.,Sari Joaquin <br /> County .Or:dinance_No q,1862�and,�thd Rules band.:,Regniatloiis of_ -,the_- San'I3o'aquizi,.Local,"He'alth 3District. <br /> ,JOB ADDRESS/LOCATION5 1S f J Ag(,CENSUS I-TRACT I <br /> y •'4{'+X�tq�'�yUA�Ja�.l zV—)�l •i.+ �CI�� �� i%i, ' -'� s�. j'i� �Iz..� Li�.r L. ^ y-:s-. 1 r, tf. r, - 1..i.1- '�1.�i/ _.. <br /> Owner.5._Name: �s f.° -so Y St:R��� r: " . ^xs U P�lOrie l.. P <br /> I - <br /> Address / eanC '�? _. .. City_` <br /> Contractor's,Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPiEN, /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / /. PUMP REPAIR / / PUMP:.`,REPLACEMENT / 7 <br /> i Other / / +✓.�._. �� a .1 <br /> DISTANCE TO NEAREST: ,SEPTIC TANK `"-SEWERILINES PIT PRIVY <br /> SEWAGE DISPOSAL' FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j Cable Tool: Dia. of Well Excavation I <br /> Domestic/privateDrilled Dia, of Well Casing <br /> Domestic/public: Driven Gauge of',Casing, t <br /> ,. <br /> Irrigation. i. .. Gravel Pack- E Depth. of. Grout Seal <br /> Other ! Rotary ' Type of Grout <br /> ! Other Other' Information <br /> PUMP, INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> �PUMP_REP.AIR: _ � /�/.� State rWork.,Done—1 <br /> ESTRUCTION OF WELLWell Die � <br /> p : Diameter 1tl.� 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 ori -a'new well, I will-fixrnislilthi i -San-Joaquin'I:ocal`"Hea17tH-'Dxst'rict 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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> /02 6t <br /> -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJAINAL INSPECTI N <br /> INSPECTION BY .�-/fes DATE INSPECTION BY DATE �= <br /> CALLr FOR A„GROUT_pINSPECTIQN_PRIOR TO GROUTING AND .FINAL INSPECTION.•-._.-,. . <br /> E H, 1426 4/72 1M <br />