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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , `Stocll-L.on, Calif. / <br /> 3 Telephone (209) 466--6781 �(G�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue _y <br /> .(Complete In Triplicate) <br /> Application is hereby made to the Saiz 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , �,, ( J CENSUS TRACT <br /> Owner's Name Phone <br /> Address '� Cf " ?z4- a�c�� ij City r ,r <br /> Contractor's Name ? .- - c , ,�, L(te _ License # Phone _) �j` % ,/7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_L� iSTRUCTION /-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 /> tmestic/private <br /> dustrial Cable Tool Dia. of Well Excavation O <br /> : <br /> %� 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 <br /> Type of Pump H.P. <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 /> rtti <br /> o <br /> %c e� <br /> SIGNED )(�? i- /, / � . TITLE �'��r ;1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f �` <br /> APPLICATION ACCEPTED BY E <br /> ADDITIONAL COMMENTS: � ~ " `�✓c ^,�' ` <br /> PHASE II GROUT INSPECTION I YIN INSPECTION <br /> INSPECTION BY DATE INSPECT O B 177 _ DATE <br /> 's <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL\IN ECTION. <br /> E H 1426 4/72 1M <br />