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--..kms... :. <br /> °N JOAQUIN LOCAL HEA' )ISTRICT <br /> " , <br /> FOR OFFI(.. -SE: 160). E. n�azelton Ave. St .cton, Calif, <br /> „ <br /> Teiepho Vie' (209) 466-6781 <br /> APPLICATION FOR WELL (^NSTRUCTION OR PUMP PERMIT Permit No. S�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 Joaqu: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION , CENSUS TRACT <br /> a <br /> Owner's Name , `� 4j_ Phon <br /> Address City: <br /> Contractor's Name License%`" Phone7?�J <br /> 'TYPE OF WORK (Check): NEW WELL / D,11 / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION 1 % PUMP REPAIR /% PUMP REPLACEMENT /-J <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 t1•--Table Tool Dia. of Well Excavation I—;t_ � <br /> �mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing •2— <br /> Irrigation Gravel Pack Depth of Grout al s <br /> Other !_ Rotary Type of Grout ,6 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �� <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 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 /> 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 is true to t e best of my knowledge and belief. <br /> SIGNED TITLE <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A Q t� <br /> ADDITIONAL COMMENTS: i �� ,n, ,� ant riga f • - 1— <br /> PHASE II GROUT INSPECTIOR✓ PHASE I /FINAL INSPECTION <br /> INSPECTION BY �►1P DATE i INSPECTION BY DATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />