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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI USE:. - ," `> 1601 E. Hazelton Ave. , Stocktou, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. e-X60. C <br /> E <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED , Date Issued 1 alp <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 incompliance 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 /> i. <br /> Owner's Name ' ) . GS Phone .� 7T, 6/22 <br /> Address l ��� S �r�-L, ������ 0(.� ,Q• City <br /> A,74112 _ <br /> Contractor's Name �,r/ � LQ ' License # LZR,323Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ I DEEPEN '/ / RECONDITION -/? DESTRUCTION /-7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR PUMP REPLACEMENT /-7 <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation: <br /> Domestic/private Drilled Dia. of Well Casing c' <br /> Domestic/public Driven Gauge of Casing o <br /> Irrigation Gravel, Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> i <br /> PUMP INSTALLATION: Contractor <br /> k <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth { <br /> Describe Material and Procedure i <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 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 fin. �n ,.�.� � {� ?� Py,Ite &. TITLE <br /> (DRAW PLO PLAN ON REVERSE SIDE) V- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL; COMMENTS: a <br /> PHASE II GROUT INSPECTION PHASE III/FINE INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY 2 �` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />