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SAN JOAQUIN LOCAL HEALTH DISTRICT 'Q"` fi <br /> FLIR` OFFICE USE: i� 1601, E..� Hazelton Ave'.,,' Sltotkton, Calif. /Uri* <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR.WELL CONSTRUCTION .OR PUMP PERMIT Permit No. 17 j - <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued / -ms=s <br /> (Complete In Triplicate) I' <br /> r Application is hereby made to the San 'Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3; JOB ADDRESS/LOCATION EIM 4 L ZRO �'�, Eit CA CENSUS TRACT <br />! ry <br /> Owner's Name ;, }, i Ir _f 0 0 Phone y/S_ SrZ� ZBt� <br /> Address POO W06 42 1�6 City 0�9&L!6 / <br /> Contractor's Name CL l L $ /,:'j9 LO/je �'s , License # G foa Phone 1-14 Z n 6—slT <br /> TYPE OF WORK (Check):. NEW WELL `�' DEEPEN /� RECONDITION /_� DESTRUCTION gr <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <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 /> I Other ` Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor _ '�� 9U 0 i P 1/y 6 , <br /> a Type of-Pump H.P. <br /> PUMP 'REPLACEMENT: / / State4Work Done <br /> PUMP REPAIR: / / State-.Work Done - y <br /> ,DESTRUCTION OF WELL: Well Diameter _. 10 Approximate Depth <br /> i. 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 willfurnish the San Joaquin Local Health Di-sfiict 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 � y TITLE �e <br /> F (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ! DATE 3 '3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> f INSPECTION BY-,- ��4: DATE 'Y-zl-9a INSPECTION BY rDATE d'' - <br /> CALL FOR A GROUT INSPECTION PR;,OR TO ROU ING AND FINAL INSPECTION. <br /> E <br /> 7/72 1M <br /> H 1426 e,-e <br /> � <br />