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lap SAN JOAI�JIN LOCALSHEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.-, 'ttockton, Calif. <br /> Telephone : (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -3,3l�(( W <br /> IIII� <br /> 9 THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued K-� -? 3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ox 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 " , CENSUS TRACT . <br /> I <br /> Owner's Name - " Phone � -- <br /> Address li City <br /> Contractor's Name _ License le �b Phone 7y.4�522- <br /> TYPE-OF WORK_(Check-)-r-rNEW WELL' 11;f- DEEPEN / / RECONDITION /-7DESTRUCTION <br /> --°-PUMP"-INSTALLATION-%4/r PUMP REPA P7- /""PUMP-REPLACEMENT--L7--- - --� <br /> Other <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGErPIT OTHER Q , <br /> ► �. <br /> INTENDED USE i! TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial- - b ale Tool Dia, of Well Excavation <br /> c3 <br /> _ Domestic/private' , , f. Drilled Dia. of Well Casing : O <br /> 1---Domesti:c/public Driven Gauge of Casing _ / 42 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �;' <br /> '� ' Rotary Type of Grout <br /> �� +� <br /> Other Other Information <br /> PUMP INSTALLATION: :I Contractor <br /> Type of,.,Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Bone <br /> Approximate <br /> DESTRUCTION OFWE_L_L: Well Diameter pP Depth <br /> Describe Material and Procedure <br /> S <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and-the-State o_fCal_ ifornia 'pertaining to or regulating well construction. Within FIFTEEN. DAYS <br /> after completion_of my"work on a newxwel-l; I will furnish the Sang Joaquin Local Health District a <br /> WELL DRIL ERS-REPORT of the well and. notify thdm before_putting the well in use. The above <br /> information is true to the best of my knowledge and belief. ! y <br /> � SIGNED ��'l ��"� TITLE <br /> (DRAW PLOT PLAN .ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE IIIGROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY it DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION..PRIOR TO GROUTING AND FINAL INSPECTION. - y, <br /> ' E H 1426 <br /> 7/72 1M �"`" <br />