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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOVOFFICE USE 1 EHazel ton:�Av!e.­-�Stoc.l <br /> kton <br /> d,�w 160 E. , Calif. <br /> Telephone�: ,'I(209) 1-466.,�6781 <br /> APPLICATION FOR WELL CONSTRUCTION',OR PUMP PERMIT <br /> Permit No. 29–M <br /> .41 A�. <br /> THIS PERMIT, �1 <br /> EXPIRES� '�YEAR;;FROM�DATE ISSUED Date IssAed'35p_ <br /> (CompleteilfiTri'plicate) <br /> Application cib).-herebyi.=detto .'therSanjJoaqiiin-Local Health District for a permit to construct: <br /> and/or install the work herein described. Thib ragplicatlon. is-made in. compliance with San Joa <br /> County,-Pr,d-inance-.,No;-il-862wand,ithbl,Ruies7 and,,Regulatibns of,, he San J quin Local HealthDistri <br /> .eq?oq , "o <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT� <br /> -o Phone <br /> Owner.'s,N Aepa, 21.1 <br /> r) <br /> Address A49 117 JV P, boy 2F537 <br /> e. C–qs-8 s city/)./j 76 <br /> A_n-r- <br /> Contracto"r"s Name License IS Phone's <br /> TYPE OF WORK (Check): NEW WEI:L:.g DEEPEN /_7 RECONDITION .7 DESTRUCTION f7 <br /> ­--d�–Pfw INSTALLATION PUMP REPAIR PUMP REPLACEMENT ./7 <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 cl <br /> Domestic/private171- <br /> Drilled Dia. of Well Casing — <br /> Domestic/public ; Driven. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other,f Rotary Type of Grout KI r) AlQ_ <br /> Other Other Information . <br /> PUMP INSTALLATION: Contractor <br /> 4 <br /> Type of Pump rLkjLr4, H.P. <br /> PUMP REPLACEMENT. State Work Done <br /> PUMP REPAIR: State Work Done <br /> .PESTRUCTION OF WELL: Well DiameterAp P roximite 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; <br /> the State 'of California pertaining to or regulating well construction. Within FIFTEEN DAY' <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT � the well and notify them before putting the well in use. The above <br /> information is o th eat of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: —T— <br /> PHASE' II GROUT INSPECTION' <br /> INSPECTION BY ,-. N% JIV�XKAL INSPECTION <br /> DATE INSPECTION BY ' v DATE <br /> CALL..KOR,.A.GRO,UT-INSPEC-T,10,N.1,P.RIOR..TO GROUTING AND FINAL.I CTON. <br /> E H 1426 <br />