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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ,0E-rCE USE: 1601 E. Hazelton Ave. , Stocktou', Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -1 z" 7 7 r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DAT: ISSUED Date Issued -L 1. 7 Z_- <br /> (Complete <br /> (Complete In Triplicate) 22z-3t0 --�3 <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 Rulec and RAaiilations of the San Joaquin Local Health District. <br /> C"OUN}P" 6 %.Jf3 _1002- <br /> JOB <br /> 1002JOB ADDRESS/LOCATION - [' CENSUS TRACT '" <br /> Owner's Name a P31 If S Phone W j s- 3 <br /> Address G ~ r �� City <br /> Contractor's Name 7 r {g �t - � License #1LLq,±2Phone <br /> TYPE OF WORK (Check) : NEW WELL 11- DEEPEN /_/ RECONDITION / / DESTRUCTION /_7PUMP INSTATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _.5-0r SEWER LINES .57J/ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD XV' CESSPOOL/SEEPAGE PIT OTHER <br /> ti <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 04 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a <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 i <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 /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) �� } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' ` ` . �+ r DATE z z 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 0- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />