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F <br /> k K SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktoa, Calif. <br /> Telephone: (209) 466-6781 <br /> /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL,4,93 <br /> f. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued 7-1z --7�i <br /> i <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 herein 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 /> JOB ADDRESS/LOC ION LUC /Gls � J9•LtLe.c1 • -� CENSUS TRACT <br /> Owner's Name Phone -3(o � <br /> Address 1/,,_ �9� ���hrht-�J-� --- City <br /> Contractor's Name License #f Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR & PUMP REPLACEMENT f� <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 /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled . Dia. ,of W611 Casing y. <br /> i Domestic/public' -rt-"" ` 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 f` <br /> L <br /> PUMP REPAIR: State Work.Done XA— _ — --- ----�—�� <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 /> 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 /> 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 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �� DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> btii <br />