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SAN JOAQU N -LOCAL HEALTH DISTRICT <br /> RF."OFFICE .USE: Vll""'1601 E. Hazelton Ave. , S. ockton, Calif. �y 7s- <br /> Telephoned (209)4,U6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��_f� <br /> I <br /> t THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made'Ato 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 Jpaquix <br /> F County Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS AOCATION �iU, G" ( CENSUS TRACT <br /> Owner's Name �/ USN' Phone <br /> Address .-e-C-e _1rjCity <br /> t i <br /> Contractor's Name f/ P % License Q <br /> ad Phone <br /> j <br /> TYPE OF WORK (Check) : NEWIWELL / / DEEPEN '/—/ RECONDITION / / DESTRUCTION /-J <br /> PUMP INSTALLATION Pi'MP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER T <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 /> i <br /> PUMP REPLACEMENT: / /, State Work Done <br /> PUMP 'REPAIR: / /, State Work Done <br /> ,DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District s <br /> [,TELL 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 GL TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY vim, DATE ' .3 / 7 6 <br /> -- -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II QROUT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY `E DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F. H 1426 5/731M <br />