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- SAN JOAQUIN LOCAL HEALTH DIS'T'RICT <br /> ;FOR OFFICE USE: 1.601 E. Hazelton. Ave. ; .Stocktor, Calif. <br /> Telephone: (209) 466-6781 <br /> E LICATION FOR WELL-CONSTRUCTION- OR PUMP PERMIT. Permit No. - <br /> THIS PERMIT EXPIRES 1 YEAR- FRO�x DATE ISSUED Date Issued , / �1-_ <br /> (Complete In Triplicate) <br /> I <br /> Application.-is hereby �made-;.to the .San Joaquin Local Health District for a permit to construct <br /> This .application- made in compliance with San Joagf <br /> and/or install the work herein described. <br /> County Ordinance No 1862 an4>the.Rules and Regulations :of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATIO H CENSUS TRACT S 7 <br /> Phone: <br /> Owner'.s Name, ` <br /> Address City <br /> Contractor's Name 4 License # _2_?/ .Phone_Uf_a <br /> k <br /> TYPE OF WORK (,Check) . NEW WELL/ / DEEPEN -/_T RECONDITION / 7 DESTRUCTIONS/ 7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> � ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing P <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> f PUMP INSTALLATION: Contractor H.P. <br /> Type` of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> „ PUMP REPAIR: <br /> ,pESTRUCTION OF WELL: Well. Diameter � � Approximate Depth <br /> r 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 /> 11WELL- 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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY g <br /> PHASE I DATE 1'9�rf <br /> i APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY A DATE — INSPECTION BY _/ - - DATE /f -- <br /> 1Y <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 lM <br /> E H 1426 ' <br />