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} <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> 1601 E. Hazelton Ave. , Stocktou, Calif. <br /> 2®RVO�FFIGE LUSE--� <br /> Telephone: (209) 466-6781 9 7 l 9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:'ZZ 9 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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/LOCATIO CENSUS TRACT <br /> (:)-TOwner's Name_,. Phone <br /> F <br /> Address U / � 7`- City , <br /> Contractor's Name /LG/•rJ License /-Phonep3�/ �-= <br /> i <br /> TYPE OF- WORK. (Check)-:' NEW WELL / / DEEPEN /7•. RECONDITION /_� --DESTRUCTION <br /> PUMP INS ATION / / PUMP REPAIR '/' / PUMP REPLACEMENT <br /> Other. /. / <br /> DISTANCE TO NEAREST: SEPTIC--TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL•.FIELD CES OOL/SEEPAGE PIT OTHER , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` Cable Tool Dia. of Well Excavation l �► <br /> Domestic/private Drilled Dia, of ,Well Casing ' (r) <br /> Domestic/public Driven 4 Gauge of Casing • <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 27" <br /> Other Other Information CA <br /> k d� <br /> PUMP INSTALLATION: Contractori� <br /> re�, e <br /> Type of Pump <br /> -•� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done _ <br /> ,DESTRUCTION OF WELL: Well Diameter Ir a -Approximate-Depth"'-.2 5- : <br /> ''Describe katerial and Procedure f <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 PORT of the we and notify them before putting the well in use. The above <br /> information s rue to the 1--sF of my knowledge and belief. <br /> SIGNED r TITLE <br /> (DRAW PL T PLAN ON REVERSE SID <br /> FO DEPARTMENT USE ONLY <br /> � PHASE I <br /> APPLICATION ACCEPTED' BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION PHASE II FINAL INSPECTION`S <br /> INSPECTION BY DATE •• INSPECTION BY DATE//4p�� "J ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ! E H 1426 Y 4/72 1H <br /> I A. .,� 1 ,,• .,.:,� <br />