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SAN JOAQUIN LOCNL IiEALT'H DISTRICT, <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stoc.',.cto:i, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z-7 7Lu <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued Ly:13-7 Z <br /> (Complete In Triplicate) ; <br /> 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. 1862 and .the Rules and Regulations of the San -Joa4uin Local Health District. <br /> JOB ADDRESS/LOCATION /{ / �� CENSUS TRACT ' <br /> s <br /> Owner's Name f C Qf'Ql2_- Phone <br /> Address 7 10 / ` / City Lvn <br /> Contractor's NameXf 4.9 4_ - License 1��� Phone Z 6 ,Z1i <br /> TYPE OF WORK (Check) : NEW WELL/�EEPEN / / RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> } <br /> Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � 3 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4-----Domestic/private Drilled Dia. of Well Casing <br /> i <br /> Domestic/public Driven, Gauge of Casing' <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout i <br /> Other Other Informat on <br /> D cs <br /> _ <br /> PUMP INSTALLATION: Con0ractor <br /> Type of PU4 H.P. <br /> r. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done w <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f <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 `4 <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. i <br /> I <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY - <br /> PHASE I j <br /> APPLICATION ACCEPTED B DATE �O .3 Z' <br /> ADDITIONAL COMMENTS: !Q / <br /> PHAS II ROL3T INSPECTIO ' PHASE III/FINAL INSPECTION ! <br /> INSPECTION BY DATE NSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING.AND FINAL INSPECTION. <br /> E H 1426 (° 4172 1M <br />