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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 160I. E.`Hazelton Ave. , Stocktoi, Calif. <br /> Telephone: (20.9) • 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-.OR PUMP PERMIT Permit No. 7Z-1?D 5 <br /> THIS PERMIT EXPIRES 1'= YEAR'FROM DATE ISSUED Date Issued -/ • '7 <br /> (Complete In Triplicate) <br /> Application is hereby,madeito the:iSan;Joaqu .n Local Health District fora 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^Rules and Regulations >of the, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ? - c A�ob1� CENSUS TRACT <br /> Id o1r <br /> Owners- Name';.' � t.. Phone <br /> AddressCity <br /> " <br /> Contractor's Nam Phone � <br /> iaensd #�7 ' <br /> � .. <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /N] DESTRUCTION /7 <br /> PUMP- INSTAL ATION / / PUA1P REPAIR / / PUMP REPLACEMENT <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 g!�, Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> -"Domestic/ptblic ~- 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: _ �. w/% .State Work Donee <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth i <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, 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 belief. <br /> t <br /> SIGNED TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> ,. I _ <br /> APPLICATION ACCEPTED BY r DATE'/Fa <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA U II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE T1-1LO <br /> CALL -FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 4/72 1M <br /> 4 <br />