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s <br /> SAN JOAQUIN LOCAL HEALTH <br /> DIS RICT <br /> iOF. OFFICE USE: 1. 1 E. Hazelton Ave. , Q <br /> F ��� Telephone: (209) 466--6781 Permit <br /> No.J�w� / <br /> APPL CATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> THIS PERMIT EXPIRES 1.. YEAR FROM DATE ISSUED � <br /> (Complete In Triplicate) <br /> is hereby made to the San Joaquin Local Health <br /> tistmade in compliancerict for a permit twithnSanuJoaqui�n� <br /> Application y <br /> and/or install the work herein described. This application <br /> X30. 1862 and the Rules and Regulations Of the San Joaquin Local health District. <br /> County OrdinanceCENSUS TRACT ' <br /> K Lv AD <br /> JOB ADDRESS/LOCATION „ Phone 1 <br /> Owner Is Name ti <br /> City ,c,Pe_f�GL � <br /> Address Phone l.,( <br /> 7 License # � 6 <br /> F <br /> Contractor=s Name <br /> / / DEEPEN r/ RECONDITION / DESTRUCTION /7 <br /> TYPE OF WORK (Check) : NEW WELL PUMP REPAIR / / Pte' <br /> PUMPIINSTREPLACEMENT /KALLAT <br /> ION / <br /> Other 1 <br /> SEWER LINES PIT PRIVY _ <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> E SEWAGE DISPOSAL FIELD _ k, <br /> ! <br /> � 'TXPE OF WELL CONSTRt3CTI0N SPECIFICATIONS C <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> IndustrialDrilled Dia. of Well Casing <br /> �- <br /> ' Domestic/private — Driven Gauge of Casing <br /> F Domestic/public Depth of Grout. Seal <br /> Irrigationi Gravel Pack P <br /> Rotary Type of Grout <br /> Other } Other Information ' " <br /> .;� Other <br /> S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f <br /> PUMP REPLACEMENT: � State Work Done <br /> PSP '`2EPAIR: State Work Done <br /> ? Approximate :Depth _ <br /> ))FcTRUCTIDN OF WELL: Weil Diameter <br /> . Describe Material and Procedure <br /> egultions oLocal <br /> I hereby agree to comply with all laws and rawe l "construction WithinaFIFTEENtDAXS <br /> and the State of California pertaining to or regulating <br /> after completion of my <br /> work on a new well, I will ,furnish the San Joaquin Local. Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. Thea ove <br /> information is true to the best of my knowledge and belief` <br /> ITLE <br /> 4' <br /> SIGNED �/ - { RAW PL ON REV i�E SIDE <br /> f 77: . .......... <br /> t FOR DEPARTMENT USE ONLX 9 <br /> " n DATE <br /> PHASE <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COENTS: 1 � , P S I FINAL INSpECTI0 <br /> MM <br /> PHASE II GROUT I SPECTION INSPECTION Y DATE <br /> INSPECTION BY DATE ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. 5/731M <br />