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"N JOAQUIN LOCAL HEALTH DISTRIC^ <br /> FOR. OFFICE USE: 164 .,.i. Hazelton Ave. , StocktOa, Cab,,,,,. <br /> Telephone: (209) 466-6781 '�7)4k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z--�/ 6 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 129 �. ���F CENSUS TRACT Sy 1 <br /> Owner's Name Phone 30 607} <br /> . <br /> Address /ac 5 // /.(J,/S �7`- City zoo/ _ <br /> Contractor's Name License ll-.171749/Phoney <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_-T RECONDITION / T DESTRUCTION /7 <br /> PUMP INS CATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER� LINES PIT PRIVY <br /> AL <br /> SEWAGE DISPO FIELD A6M CES POOL/SEEPAGE PIT _hkij,_�OTHER 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. of Well Excavation ..f. <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout .270/ ,reads h1� <br /> Other Other Information <br /> Ay <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A (t _CZSa&4,r H.P. ` A„ <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth SL) <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 <br /> DRILLERPORT of the we , and notify them before putting the well in use. The above <br /> information s rue to the s of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PL T PLAN ON REVERSE SID <br /> PHASE I FOP4 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYz i_ j`fi DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II INSPECTION PHASE TIT/FINALINSPECTION <br /> INSPECTION BY GROUT DATE S!E: j- 1 `L INSPECTION BY 7?7,' DATE . ,% <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />