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SAN JOAQUIN LOCAL I]ZALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'Ave. ;'Sfockton, Calif. <br /> Telephone:' (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L-�f{ °f <br /> THIS PERMIT EXPI=RES .1 YEAR..FROG'!-DATE ISSUED: -'Date Issued 6-;30-_7z'_ <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:,; 1862rand:`.the -Rules and. Regula.tions�bf the San'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��'j 3 �,�� , �,� { CENSUS TRACT, � <br /> Owner's Dame ' "M w To <<: Y:x rKx: , Phone <br /> Address9,,g0-'2----L,,- - City_ <br /> Cont, _ <br /> .. .._ ..- .- :.. ..... , <br /> Gt c �i wc? O � License # Phone <br /> actor's'Name � � � 7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/ j RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION `/ / 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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable .Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <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 /> PUMP INSTALLATION: Contractor a <br /> Type of Pump /G F ON <br /> .P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP=REPAIR:,.:a / / -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 regulatingwell 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 REP RT of the well and notify them before putting the well in use. The above <br /> information i Ve to the -est- of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASR III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY //� DATE - ,�- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ 4/72 1.:1M <br /> r <br />