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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> rw FOR OFqi ( <br /> 1601 E. Hazelton Ave;, Stockto..,, Calif. <br /> E Telephone (209), 466-6731 <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Permit No. 72-- .55 <br /> IS .PERMI --- EXPIRES 1: YEAR FROM DATE"ISSUED Date 7Issued <br /> 6-1.3.72/ <br /> (Complete "In Triplicate) <br /> Applicaothe San Joaquin Isocal Health District for a permit to construct <br /> and/or nstall thwork herein described. This application: is made in compliance with San Joaquin <br /> County Ordinance No. 1862 nd the 'Rules' and egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, - CENSUS TRACT " S <br /> Owner's Name . y r }: �- 3� Vo <br /> Phone j <br /> Address .2 Z <br /> City . <br /> Contractor's Name License Phone N <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP IN5T ATION / / pUMPIREI'AIRf PUMP"REPLACEMENT"'/.�-=-Y <br /> F Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS pQ <br /> Industrial �� Cable Tool Dia. of Well Excavation �! <br /> Domestic/private Drilled Dia. of Well Casing 4✓ <br /> Domestic/public Driven Gauge of Casing <br /> �.V,' Irrigation Gravel Pack Depth of Grout Seal (� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 1.1 <br /> Type of "Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,PESTRUCTION OF-WELL— Well'Diameter"' <br /> Approxrimate Depth - <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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - J y <br /> CALL FOR A GROUT INSPECTIONPRIOR..TO GROUTING AND FINAL INSPECTION. W`-* <br /> E H 1426 4/72 1M <br />