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jY „' SAN JOAQUIN LOCAL HEALTH DISTRICT � + <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockto ,, Calif. <br /> - Telephone.: (209) .466-G781 f <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 15 `7a <br /> vi (Complete In Triplicate) <br /> Application is hereby tirade 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �r �" �6(ct � Phone <br /> Address �a-eV2 -r/�f�J ' �'� City <br /> Contractor's Name _CSC,./fes �j '�.�- 3. ¢_ License Phone Phone 14�� J��'�( <br /> TYPE OF WORK (Check) . NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION t4 PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK J SEWER LIKES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing - - J <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth�. of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other Information ; <br /> . o <br /> PUMP INSTALLATION: Contractor <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 Approximate 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 orregulating 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 REPOR the well and notify thiem before putting the well in use. The above <br /> information is trSw6 est o my kedge and belief. <br /> SIGNED 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 II GROUT INSPECTION -- PHASE III/FINAL INSPECTION <br /> INSPECTION BY a' DATE P -At,/ ., INSPECTION. BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />