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`FO FFICE USE: ` SAN JOAQUIN LOCAL HEALTH bISTRICT <br /> 1601 E. Hazelton Ave. , <br /> Stacktor, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> ! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> (Comp <br /> Application is hereblete In Triplicatd) Date Issued <br /> y' made to the .San Joaquin Local health Districtpermit <br /> and/or install the work herein described; This aPplication is made inrcompl ancetwitco <br /> hnSanuJoa "uin. <br /> i County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CESIP <br /> NSUSTRACT <br /> Owner's Name <br /> Phone ' /� <br /> Address — �_ <br />� S'�G- � <br /> City , s .�`7✓rtr , C� <br /> Contractor's Name <br /> License #---- //� Phone <br /> TYPE OF WORK (Check) : NEW WELL ------- <br /> -L�DEEPEW /_/ RECONDITION /% DESTRUCTION <br /> PSP INSTALLATION <br /> /:/ PUMP REPAIR /—/ PUMP RE <br /> pLACEMEN- /- r <br /> Other E7 _ .7-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL—FIELDWER LINES PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial , CONSTRUCTION SPECIFICATIONS <br /> �d--Cable Tool .Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Domestic/public Dia• of Well Casing <br /> -~� �� Driven Gauge of Casing <br /> 7-0 <br /> _4G Irrigation Gravel Pack <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> _..—,.,T_ype._of_Pump�_ <br /> - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: - <br /> --State Work Done <br />.DESTRUCTION OF WELL: Well Diameter <br /> _ Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with-all laws and regulations of the San Joaquin <br /> lth—District <br /> and the State of California pertaining to or re'g`ulating well construction.LoWithin 11 H aFIFTEEi4 DAYS <br /> after completion of my work on a new well, I wi11 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them?before putting therwell in use. The above <br /> information istrue to the best of my knowledgetl'and belief. <br /> t <br /> SIGNED - <br /> JF TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE). -- <br /> PHASE I FOR DEPARTMENT USE ONLY Y <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 2 <br /> PHASE II GROUT._INSPECTION <br /> INSPECTION By PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY DATE _ Z <br /> ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4/72 1M <br />