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SAN JOAQUIN LOCAL HEALTH DISTrTCT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.', Stockto,�., Calif. <br /> Telephone: (2 09) <br /> 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F <br /> THIS, PERMIT MIRES 1 YEAR FROM DATE ISSUED Date Issued.j:�z­ Iz_- 6. <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 herei' described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name, <br /> C CityC,' r2� <br /> Address <br /> Contractor's Name License # Phone &a;,�z <br /> i <br /> TYPE-OF-WORK.=(Check) :- NEW-WELL -DES.TRU.GTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other il / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ra - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation j <br /> k Domestic/private # Drilled Dia. of Well Casing <br /> Domestic/public. - i 'Driven Gauge of Casing <br /> f Irrigation Gravel Pack. Depth of Grout Seal �} <br /> Other F Rotary Type of Grout <br /> Other <br /> Other Information <br />} <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type ,of Pump <br /> PUMP REPLACEMENT: / / State Work Doned � � <br /> f PUMP REPAIR: / State Work Done <br /> --Approximate Depth _ <br /> p TRUCTION OF WELL: Well Diameter . . . . <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District_ <br /> i 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 /> If is true to the best of my' knowledge and belie€. - - <br /> kY TITLE <br /> :SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED EY._ _ <br /> ADDITIONAL COMMENTS: # <br /> PHASE IT GROUTtINSPECTION PIiA E III/ INAL INSPECTI <br /> N <br /> INSPECTION BY 2DATE ___ INSPECTION BY DATE <br /> CALL FORA GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. 4./72 1M <br /> E H 1426 <br />