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JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE:, 1601 Hazelton Ave. Stockto:-, Cali <br /> Telephone: (204) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2- 3 p <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y Z, -7 z- <br /> (Complete In Triplicate) <br /> )plication is hereb ma to the San Joaquin Local Health District for a permit to construct <br /> Ad/or install the work he �,ein described. This application is made in compliance with San Joaquin <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> DB ADDRESS/LOCATION CENSUS TRACT <br /> �C r <br /> aner's Name �/df /�ar���Sb�_ Phone <br /> idress y E&,/Q_- <br /> ontractor's Name ivy ' 2_ g�r��� p�� License Phoned <br /> YPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION I I PUMP REPAIR '/ / PUMP REPLACEMENT -7 <br /> Other <br /> 'ISTANCE TO NEAREST: SEPTIC TANK L r SEWER LINES _ , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHE <br /> INTENDED USE TYPE OF WELL „ / CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool a.!Lof Well Excavation -- <br /> Domestic/private Drilled -,/ of Well Casing N <br /> Domestic/public Driven • Ga ge of Casing <br /> Irrigation Gravel Pack epth of C/ out Seal <br /> Other Rotary pe 0fl/ t:out <br /> Other �Other�Iuformation <br /> ` r <br /> 'UMP INSTALLATION: Contractor ,E 2t� <br /> Type of Pump H.P. <br /> ?UNP REPLACEMENT: / State Work Do ` l �pf�� �'-5 40 <br /> ?UMP REPAIR: / / State Wor Don <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 s 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 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE j <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />