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_ 1V JOAQUTN LOCA <br /> 11 ALTH DISTRICT <br /> FOR OFFICE bSE:- gF ]_60 Hazelton Ave. , Stockto-, Cal: <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRICTION OR PUMP PERMIT Permit No. <br /> \THIS PERMIT EXPIRES 1 YEAR FROM DATE ;ISSUED Date Issued � 2 3 , 7 L <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 <br /> County Ordinance No. 1862-,&-ad the Rules and Regulations of theS Health District. <br /> JOB ADDRESS/LOCATION S �,Q, ,ice C SUS RACT <br /> Owner's Name �� �-- ?. i L _ _/� A� 9 .----- Phone <br /> 76C 040--V <br /> Address &IQ City <br /> Contractor's Name <br /> 7' License # Phone me -Ott <br /> 4 <br /> TYPE OF 'WORK (Check) : NEW WELL / / Drn�aN / ! RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /�/ PUILIP REPAIR I / PUMP REPLACEMENT <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private . Drilled Dia, of Well Casing NA <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 /> PUMP INSTALLATION: Contractor Q~ <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 57' 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 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 /> f (DRAW PLOT PLAN ON REVERSE SIDIC <br /> PHASE I <br /> FOR PARTMENT USE ONLY <br /> r <br /> APPLICATION ACCEPTED BY � '�' - DATE K f. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' • DATE 7=a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />