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SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stacktoll, Calif. <br /> Telephone: (209) 466•-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7 2-- 5 5 Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-t.-3- 77-- <br /> (Complete <br /> -E3- 7z(Complete In Triplicate) <br /> Application is hereby de to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work erein 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 "g e CENSUS TRACT <br /> Owner's Name A4 Af S erk 7' Phone <br /> Address ,+�,�,�pcity <br /> — <br /> CQatractor's Name License # Phone est. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /-7 DESTRUCTION 17 <br /> PUMP INSTALLATION /�/ PUMP REPAIR A;-- PUMP REPLACEMENT /- <br /> Other <br />- DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,M Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing E <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H.P. ; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done p F& ph/ 1/ ` �- ► <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth i <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 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 TITLE PN 7-)yd kr- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Ccs DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAN III/FINa INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 <br />