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l4velel� SAN JOAQUI•N -LOCAL HF.ALTIT DISTRICT <br /> ' FOR l4FFIC11 USE: / 1601 E. Hazelton Ave. ;%S-tocktor:, Calif. <br /> t YYY Telephone: (204) 466=6781 <br /> a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '�3���9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued 4-1 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO � �� ����✓��o//�dSev/Coad CENSUS TRACT <br /> Owner's Name PC"pce- l/ " �t�. V4- c!�"�!e C� Phone ' 3.3�C7 <br /> 'Address r D_ fY City <br /> Contractor's Name License llPhoneS6 <br /> ' TYPE OF, WORK (Check):_ NEW WELL /_DEEPEN/ / _RECONDITION /�M DESTRUCTION / - <br /> �� �"- PUMP INSTALLATION R PUMP-.REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '- CESSPOOL/SEEPAGE PIT OTHER <br /> a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O � <br /> Industrial - Cable Tool Dia, of Well Excavation °/ r <br /> Domestic/private Drilled Dia. of Well Casing .J� i <br /> Domestic/public Driven Gauge of Casing /Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Other Rotary Type of Grout A/p���L <br /> Other Other Information ' <br /> V! 1, <br /> ' PUMP INSTALLATION: Contractor <br /> Type of Pump /1/1Lorr /42 H.P. `i <br /> PUMP REPLACEMENT: / / State Work,Done <br /> ti <br /> PUMP REPAIR, / / State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproxi'mafe Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District, V <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 REPO - f the well and notify them before putting the well in use. The above - ) <br /> information is t e to the best of knowledge and belief. {1 <br /> ' <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION INSPECTION BY h, /-/ 11- P-23DATE INSPECTION BY DATE 11- p` <br /> ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.I. b14 R <br /> E H 1426 4/72 1M <br />