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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton_Ave. , St-ockton,. Calif. <br /> Telephone {209.) .466';6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L <br /> i <br /> THIS PERMIT- EXPIRES .l YEAR FROM,�DATE- ISSUED Date Issued <br /> .sig - r, ,t <br /> (Complete In 'Tripli'cate) <br /> Application is. hereby de to theSan Joaquanr Local Health District for= a .permit to construct <br /> and/or install the wor In described. This :.applicition, is made .in compliance with ,San,`Joaquin <br /> County Ordinance ,No..,1862 .arid ,-the ,Rules. and, Regulations of .the San Joaquin Local health District, <br /> Ll ri <br /> JOB ADDRESS/LOCATION A/31�eA6 T " CENSUS TRACT <br /> Owner',s` Name`+� /. ...,' F: t �:a a - _ Phone d, <br /> Addresses City <br /> Contractor's Name _ License # Phone ' <br /> 7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENI / RECONDITIONI DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> :r Q <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing m <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout-,Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 0, aL . <br /> PUMP INSTALLATION: Contractor , . <br /> H.P. <br /> Type of Pup`• T <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 the best of my knowledge and belief. <br /> f y <br /> SIGNED <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. DATE �� _ <br /> APPLICATION ACCEPTED BY -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A_GROUT .INSPECTION_PRIOR_TO GROUTING .AND FINAL INSPECTION. _ <br /> E H 1426 4/72 1M <br />