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SAN JOAQUIN LOCAL, I)ZALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haze1tonAYe. ,,, Stock1ton, Calif. <br /> Telephone: ..,(20'3) <br /> APPLICATION FOR WELL' C6NStRUCTION.AOR PUMP PERMIT Permit No. <br /> THIS PERMIT,:EXPIRES..l LXEA-R1;FR011,1(,DATE­ISSUED -!(Dat: <br /> ' (Complete lftl�,-TtiplitatO <br /> Applicati,oril,ig::Jhdreby-,,,mad-e,-tt,o the(,Saiy�-Joaqu�ntLodal, Healfh <br /> and/or install the work herein described. This izappl.ication%is-�made.`&n icompl'ian'ce wkth San'--Joaquin <br /> County-0rd-inafice c.No.-,r,186,2 iiandvthe',;Rulea --and Regulations--6f the San-­16aqujjj,Local-:-.Realth!'.District. <br /> JOB ADDRESS/LOCATION <br /> o-TT 77,71 :k 5. <br /> Owner!.9 EN4im&ol <br /> Address City. <br /> . Contractor's NameLicense # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR// ,/ PUMP REPLACEMEN <br /> Other . <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 <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. . /tate Work Done <br /> PUMP REPAIR- State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby <br /> reby 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 be <br /> 7 76?:e-,4r,40- <br /> SIGNEDTITLE <br /> (D-RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-ju FZNAL INSPECTION <br /> /j, <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR,TO GROUTING AND FINAL INSPECTION.,---, <br /> E H 1426 4/72 1M <br />