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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR .OFFICE USE: 1601 E. Hazelton Ave. , Sto6:.coy,, Cao <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERF1IT Permit No. I <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2,0.-7 z.- <br /> f (Complote. 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 Rule-s' and Re uiations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ZJ64CENSUS TRACT <br /> Owner's Name :z Phone <br /> �i <br /> A City L`��,✓: <br /> Cont actor cName License # l i 373 Phone Z4Z-���j'; <br /> I`YPE; OF�WORK QCheck) :. M NEW WELL. / _/ <br /> DEE PEN /_ / RFCONDITION /-7 DESTRUCTION /-7 ✓ <br /> `'. PUMP INSTAL ATION / / PUMP REPAIR / '/ PUMP REPLACEMENT f� <br /> Other ZX/ �;. <br /> r TANCE TO:�NMREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> ----I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER <br /> Cao <br /> ;3 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ii . Industrial. I Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing (1!} <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> § Other I Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. CA <br /> :i <br /> PUMP REPLACEMENT: / / State Work Done <br /> II _ � <br /> PUMP REPAIR: / / State Work Done <br />,_DESTRUCT.ION OF, WELL: ,-Well-Diameter.,_.. �_ � - --�- �._Approximate_Depth _i_---_ w <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 FIFTEEN DAYS <br /> after completion of my work cit a new well, 1 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 <br /> � - .0 TITLE �� <br /> (DRAW PLOT ON REVERSE SIDE ._— <br /> ` FORD ART MENT USE ONLY <br /> PHASE I � r <br /> APPLICATION ACCEPTED BY 'L ,� � �.. � DATE <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION P114,S& III/FIDIAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/7.2 1M <br /> II <br />