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SAN JOAQUIN LOCAL HEALTH DISTRTCT r ,y <br /> 70TOFFICE USET 101 E. Hazelton Ave. , Stockto* .¢ : <br /> 'Telephone: (209) 466-!:6 <br /> APPLICATION FOR"WELL CONSTRUCT-10-OR. PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .y-2a-1Z <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/LOCATION 7 oI Al ? Kd 1-1 o -s2- - -: _--- CENSUS TRACT , <br /> Owner's Name t`740 Phone <br /> Address -si4�r� City ,-4 Sc i LO t) <br /> Contractor's Name /j ��p�EJ --- ---- -- License #27903Phone 39 <br /> - TYPE OF WORK (Check) : NEW WELL /% DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / '; 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 X IR <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 /> PUMP REPLACEMENT: / / State Work Done <br /> 'UMP '�tEPAIR: / State Work Done <br /> „DFATRUCTION OF WELL: Well Diameter Approximate Depth <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 <br />{ (DRAW PLOT PLAN ON REVERSE SIDE <br /> a <br /> FOR DEPARTMENT USE ONLY <br />€ PHASE I <br />+, APPLICATION ACCEPTED .BY �' DATE dr' Z? �3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P 4KS, II /JINAL INSPECT O <br /> INSPECTION BY DATE INSPEC N BY ATE <br /> CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. ,J <br /> — .. .ter /7ltu <br />