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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , St6ckt6n, Calif. <br /> Telephone: (209) 466. 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED ; Date Issued -7 7- <br /> (Complete In Triplicate) <br /> Application is hereby made 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 E <br /> County Ordinance No. 1862 -and the Rules and Regulations of the San Joaquin Local Health District. <br /> 7 figAl -D Ah i <br /> JOB ADDRESS/LOCATION oAe( #f26 CENSUS TRACT <br /> Owner's Name Phone ' <br /> j" <br /> Address O?3f4 /�/ �1C', 7�S1GJ V RD -- City , <br /> Contractor's Name C-1*6 lG /LL-1A/ i��Cl� License ��� Phone <br /> TYPE OF WORK (Check) : NEW WELL..Y/ DEEPEN -/_/ RECONDITION /-7 DESTRUCTION / <br /> AL <br /> PUMP INSTLATION., PUMP REPAIR /—/ PUMP REPLACEMENT_ /- <br /> Other <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS } <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> Domestic/private Drilled Dia, of Well Casing <br /> 42 <br /> Domestic/public Driven Gauge of Casing j <br /> y Irrigation Gravel Pack Depth of Grout Seal SO <br /> Other Rotary Type of Grout _- <br /> Other Other Information a <br /> 1 <br /> t7Z, <br /> PUMP INSTALLATION: Contractor „y <br /> Type of Pump ra- H.P. O <br /> S <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> Ik, ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> G Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t and the State of California pertaining to or regulating well construction, Within FSFTEEI 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) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c� <br /> APPLICATION ACCEPTED BY DATE �a- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 2-r--7 2-- --- . INSPECTION BY DATE ��-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. W� <br /> E H 1426 4/72 1M <br /> I <br />