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SAN JOAQUIN LOCAL HEALTH DISTRICT "D a/ <br /> FOR OFFICE USE: 1601 E. Hazel ton 'Ave. S.tbcktort, Calif. vl— <br /> Telephone:. �(209)'k,_ 6b---6781 <br /> APPLICATION FOR WELL CONSTRUCTION,.OR PUMP PERMIT Permit No. Z y$6 S <br /> THIS PERMIT IRES 'l ..XEAR:"FROM DATE ISSUED- Date Issued 4 -13`7 Y. <br /> n s ; (Comple-te In Triplicate)Applicationtis ,hereby-ma e _to thei�,Sanc,loaquin.",Local.Health District for a permit to const uct <br /> and/or install the workJherein described. This..application is 'made in compliance with Sa Joaquin <br /> County OrdinancetNo: _1862, and}the.Rules and-:ReGgulatkons o the San Joaquin Local Health D strict. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> aq <br /> Ownerrs::Namef ! =�3 y ": a pct d,�c'rr/ , ;;�1 x l Phone . <br /> AddressCity <br /> Contractor's Name 11jjZ/ZD } License # Phone <br />'e _.TYPE OF,WORK-(Check):---..NEW, WELL-/ /..-,.DEEPEN L/;, ;RECQNDITIONx/._/ /_7DESTRUCTION � ._. <br /> PUMP INSTA LATION '/T PUMP REPAIR PUMP REPLACEMENT /_7 r i <br /> Other. / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL r �� CONSTRUCTION SPECIFICATIONS <br /> Industrial CableTool > 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 /> LOther Rotary r Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor _ <br /> I Type of Pump . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / C5`/ State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth � a <br /> Describe Material and Procedure ° <br /> j <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 /> F <br /> 4 <br /> SIGNED { 1 ] TITLE <br />'F ' <br /> (DRAW PLOT PDAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY k <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FORA GROUT-INSPECTION-PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> E H 142b 4/72 1M <br /> i <br />