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a} <br /> 1� I <br /> /G _SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L OF. OFFICE USE.- 1601 E. Hazelton Ave. ,`-S>rockton, Calif. <br /> a Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G1— 9 I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z2-714, <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 Joaquin ' <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health Di,stri,ct. <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> I <br /> Owner's Name C3 Phone <br /> Address f City ! <br /> Contractor's name + "7�� J � Jb,J Licensed , !)j� Phone <br /> TYPE OF WORK (Cheek) : --NEW WELL DEEPEN '/% RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT l� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAiINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE -OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private — - Drilled Dia, of Well Casing , <br /> Domestic/public Driven. ' Gauge of Casing i <br /> Irrigation Gravel Pack "" %Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J J State Work Done 1�� - <br /> h111 <br /> PUMP 2EPAIR: __ / /. _State. Wo_rk..Done - - ' lJi►� <br /> t <br /> .DFgTRUCTION OF WELL: Well Diameter ,3 "Approkimate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District i <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 /> SIGNED TITLE <br /> C7 j11zL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I ---- , <br /> APPLICATION ACCEPTED BY C - DATE <br /> ADDITIONAL COMMENTS: a`r � <br /> PHASE II GROUT. INSPECTION PHASE II,14F4 L INSPECTION I <br /> INSPECTION BY BATE INSPECTION BY DATE <br /> w- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ra /70�.. <br />