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� :iA1J JC%.C� �Iiv %.0+.�,":_ :^•.DTII '�'IST'?ICT <br /> FOR OFFICE USE: -L o0' E. Hac: `or. Ave St -, <br /> tock CaIi s <br /> Telephone (209) 466-61781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> ,r THIS ERIalT EXPIRES 1 YEAR i' OM DAT-_Z ISSUED Date Issued <br /> (Complete In triplicate) <br /> 'pplication is hereby made to re San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> `bounty Ordinance No. 1862 and rtheules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION 6 - - CENSUS TRACT <br /> f <br /> Owner's Name �` �� !r" Phone , <br /> address -�' ��C" <br /> ^ontractor's Name `C�:C r %f. _. _ License ��fUc-�'�<</ Phone <br /> TYPE OF WORK (Check) : NEW WELL _Ike- DEE EN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR J / PUMP REPLACEMENT /_7 <br /> — Other <br /> ISTANCE 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 f',? <br /> Domestic/private u Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �. <br /> 7UMP REPLACEMENT: / / State Work Done <br /> JIQ REPAIR: / / 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 /> ^nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Eter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'WELL DRILLERS REPQRT' of the well and notify them before putting the well in use. The above <br /> information-is- ue to the best of my knowledge and belief. <br /> �,_IGNED "f <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i` <br /> FOR DEPARTMENT USE ONLY <br /> -IASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I4 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 'NSPECTION BY DATE io 7 INSPECTION BY <br /> DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 C4/72 1M <br /> �5 <br />