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' y <br />SSAN JOAQUIN LOCAL HEALTH DIS'T'RICT <br />1601 E. Hazelton Ave., Stocictor., Calif. <br />Telephone: (209) 466-6781 <br />VAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />THIS PERMIT EXPIRES 1 YEAR FR'0M DATE ISSUED Date Issued <br />(Complete In Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit o co scruct <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 41 7c2lp 18� .4�.�.QUE.rr�- ��,40, M LO CENSUS TRACT <br />Owner's Name 74 gE Phone <br />-� i a 0 ._ <br />Address%Q1 �' ��/��-��c �'f` %�✓i�4�fnCit-_ <br />y <br />Contractor's Name Q'� �/ �!��// �� �y �i�1iC7 <br />license # phone <br />TYPE OF WORK (Check): NEW WELL >� DEEPEN /—/ RECONDITION /_% DESTRUCTION /_7 <br />PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br />Other / / <br />DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER LINES <br />PIT PRIVY <br />Ud Tl <br />SEWAGE DISPOSAL FIELD <br />_ <br />CESSPOOL/SEEPAGE PIT OTHER <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />Industrial <br />__,__-8able Tool <br />Dia. <br />of Well Excavation <br />/ Domestic./private <br />Drilled <br />Dia, <br />of Well Casing <br />Domestic/public <br />Driven <br />Gauge <br />of Casing fa <br />Irrigation <br />Gravel. Pack <br />Depth <br />_ <br />of Grout Seal <br />Other <br />Rotary <br />Type <br />of Grout <br />Other <br />Other <br />Information <br />j <br />PUMP INSTALLATION: <br />Contractor <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />.DESTRUCTION OF WELL <br />Type of Pump <br />.P. 12— <br />State <br />— <br />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 DRILLS S REPORT of the well and notify them before putting the well in use. The above <br />InformaEtg i trp to the best of my knowledge and belief, <br />s i <br />SIGN <br />TITLE <br />PLAN ON REVERSE SI ) <br />FOR DEPAR NT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE, II GROUT INSPECTION <br />INSPECTION BY � DATE %} r .7 <br />DATE=p��y <br />PHASE -1 FINAL INSPECTION <br />INSPECTION BY �/ DATE 7-,7-,!,,-- -7v` <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426 4/'72 1MM <br />State <br />Work Done S�UG� G—Xi S'T.[r�'���o <br />Ud Tl <br />State <br />Work Done <br />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 DRILLS S REPORT of the well and notify them before putting the well in use. The above <br />InformaEtg i trp to the best of my knowledge and belief, <br />s i <br />SIGN <br />TITLE <br />PLAN ON REVERSE SI ) <br />FOR DEPAR NT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE, II GROUT INSPECTION <br />INSPECTION BY � DATE %} r .7 <br />DATE=p��y <br />PHASE -1 FINAL INSPECTION <br />INSPECTION BY �/ DATE 7-,7-,!,,-- -7v` <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426 4/'72 1MM <br />