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SAN JOAQUIN LOCAL RE.F LTI DISTRICT <br /> FOR OFFICE USE: :1601. E. Hazelton Ave. , StnckL-oa}., Calif. . <br /> Telephone. (209) 4a6- 3;1"7_ <br /> APPLICikTION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70 <br /> THIS PERMIT EXPIRES 1 YE-,",R FROM DATE ISSUED Date Issued <br /> (Complete In 'iriplirate) <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6(. 0j- �j, / CENSUS TRACT S , <br /> Owner's Name Phone 3 d () <br /> Address �. (� - 1 City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN /_� RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR M PUMP REPLACEMENT /? <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED - <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation S <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 <br /> Type of Pump H.P. <br /> IC <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 <br /> i 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 /> F 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 /> SIGNED TITLE <br /> j DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2— <br /> ADDITIONAL COMMENTS: <br /> PHAS II T NS N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY zq, DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />