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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E97!7 <br /> .1601 E. Hazelton"Ave.,• StocktoL., Calif. <br /> I Telephone: . (209) 4'66--6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit :o. <br /> ,�412 <br /> fiHIS PERMIT EXPIRES <br /> 1 YEAR FROM- DATE ISSUED Date-"Issued ���'� <br /> (Compl'ete In Triplicate) /T 6 D -f <br /> 4 Application is-hereby made to the San. Joaquin .Local Health District for a petmit-to construct <br /> and/or install the work herein described. This ,applicatiort is made in compliance with San Joaquin <br /> County -Ordinance No-.,,1862 arrdFthe Rules and Regulations•of-the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONR_=�, <br /> F. s cl _ CENSUS 'TRACT <br /> Owner,'s-:Name �!? <br /> 'n. Phone <br /> Address <br /> City <br /> Contractor's Name TY <br /> License # 2?9 Ann Phone '369-8471 . <br /> x - <br /> TYPE OF WORK (Check) : NEW WELL :F / DEEPEN.,/—/ RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS �+ <br /> Industrial iCable Tool Dia. of Well Excavation <br /> Domestic/private , Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing , <br /> �x Irrigation i Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> 1 Other Other Information <br /> } <br /> PUMP* INSTALLATION: 4 <br /> Contr ac for 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter f <br /> Approximate Depth � <br /> Describe Material and Procedure <br /> h <br /> I hereby agree to comply withiall 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 puttin the well in use. The above <br /> information is true to the best of my knowledge and belief <br /> SIGNED ` <br /> nmp TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED BY F <br /> ADDITIONAL COMMENTS: DATE ��/- ` <br /> PHASE II GROUT INSPECTION . PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH 1426 � . <br /> 4/72 1M <br />