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SkN JOAQUIN LOCAL HEALTH nISTRICT <br />FOR OYFICE-U—SE 1601 B. Hazelton kve.r.-Stockto-zi, Calif. <br />Telephone: (209) 4066-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 0 <br />ja THIS PERMIT EXPIRES I YEAR FROIlf DATE ISSUED Date Issued <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 compliance with San Joaquin <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION CENSUS TRACT <br />Owner's Name Phone <br />Address Ci ty <br />Contractor's Name License Phone <br />TYPE OF WORK (Ch6ck) t NEW WELL DEEPEN j J RECONDITION DESTRUCTION <br />- <br />PUINSTALLATIONZPL�T REPAIR PUMP REPLACEMENT /7 <br />Other / / <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />INTENDED USE <br />Industrial <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Other <br />OF <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />CON. <br />F1 <br />Dia. of Well Excavation <br />Dia. of Well Casing A, - <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />P11W INSTALTATTON't Contractor <br />PUMP REPLACEMENT - <br />PUMP REPAIR: <br />.DESTRUCTION OF WELL: <br />Type of Pump <br />/—/ State Work Done <br />/-/- State Work Done <br />H. P. <br />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 />and the State of California pertaining to or regulating well construction. Within FIFTEEii 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 i.*_true t9 the best of my knowledge and belief. <br />SIGNED <br />TITLE <br />PLOT PLAN ON REVERSE SIDE) <br />FOR DEPARTMENT USE ONLY <br />PHASE 1 <br />APPLICATION ACCEPTED BY DATE -/,0 <br />'LIONAL COMP NTS: <br />PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br />INSPECTION BY DATE R -) 114;p -�L/ <br />INSPECTION BY DATE &:' - -7 2- <br />�Ho <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. to <br />E H 1426 4/72 1M <br />