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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E USE: <br /> llVll' """ 1601 E. Hazelton Ave, , :Srockton, Calif <br /> FOR OFFIC . <br /> Telephony. (209} 466-6781 ' p <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. F <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM BATE ISSUED � <br /> (Complete In Triplicate) y6 0, <br /> ct <br /> Application is hereby made to the San Joaquin: LocallicaHealth <br /> ion istmade 'inrcom liancetwith nSan uJoaquin <br /> and/or install the work herein described. This -app <br /> P <br /> County Ordinance No. 1862 and the- Rules and Regulations. o£ the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> W?__ ;� <br /> Owner's Name _- <br /> c- l ��frr /� �' .6 City ,� �Ive5,�v <br /> f Address <br /> Contractor's Name License 4��� Phone ' G <br /> ...........-F DEEPEN 'J J RECONDITION / DESTRUCTION /�T <br /> TYPE OF WORK (Check) : NEW WELL / pUjqP REPAIRI J PUMP REPLACEMENT I� <br /> PUMP INSTALLATION JJI <br /> Other J J <br /> DISTANCE TO NEAREST: SEPTIC <br /> _TANK SEWER LINES %/J__ L'IT PRIVY <br /> SEWAGE DISPOSAL FIELD —. . CE SPOOL/SEEPAGE PIT OTHER <br /> TYPE OF WE <br /> INTENDED LL CONSTRUCTION SPECIFICATIONS ` f <br /> f USE <br /> Industrial Cable Tool Dia. of Well Excavation �_ <br /> Dia, of Well Casing , <br /> Domestic/private Drilled Gauge of Casing I <br /> Domestic/public Driven g g <br /> ! �� Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Rotary Type of Grout <br /> Other Other Information" <br /> Other r <br /> Y <br /> rs PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> �• PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: .State Work Done <br /> Approximate Depth <br /> ,pESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> rict <br /> I hereby agree to comply with all laws and regulat �in owell econstruction.uin LoWithin FIFTEEN <br /> San cal Health <br /> tDAYS <br /> and the 'State of California pertaining to or regulating <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 the best of my knowledge and belief. M - <br /> k SIGNED TITLE <br /> F (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' <br /> APPLICATION ACCEPTED $Y <br /> ADDITIONAL COMMENTS: PHAS III/FINAL INSPECTION <br /> PHAS II GROUT INSPECTION INSPECTION BY DATE — �- <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />