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' SAN JOAQUIN LOCAL INEALTH DISTRICT v <br /> FOR OFFICE USE: 1.601 E. Haze' ton Ave. ,' Stoc-;_t­):A , Calif. € <br /> Te1..aphone: (201): 4.66' 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP PER�411T Permit No. Z_ <br /> THIS PERMIT,EXPIRES l YEAR FIRGY1 DATE ISSUED Date Issued Z 7 y <br /> I ;.' ' . (Complete In' Tripi:icate} . <br /> Application is her by..made- to the:�San.,Joaquin.. Local Health District for a permit to- construct 4 <br /> and/or install the work herein' described. .This application is' made .in:compliance with San Joaquin <br /> County. Ordinance Noir?1$62.=and, thee.Rules and Regulations of-'the San Joaquin Local Health- District. <br /> 560-'S <br /> JOB ADDRESS/LOCATIO CENSUS-TRACT <br /> Owner's. Name:. <br /> Phone <br /> Address Cit <br /> Contractor's Name License # Phone et <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ ' RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUIiP REPAIR / / PUMP REPLACEMENT / Y <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grouts <br /> I Other Other Information P. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum <br /> H.P. <br /> PUMP REPLACEMENT. /per/ State Work Done <br /> PUMP REPAIR, I <br /> Z77 State Work Done <br />.DESTRUCTION 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 o the best of my knowledge and belief. <br /> SIGNEDI - �2TITLE <br /> (D PLOT PLAN ON REVERSE SjDhgAoc�__ <br /> PHASE I O DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II I SP T PHASE III/FINAL INSPECTIqN <br /> INSPECTION BY ATR INSPECTION BY DATE \EETAInx <br /> i <br /> CALL FOR A GROUT INSPECTION''.PRIOR TO GROUTING AND FINAL INSPE6RON. <br /> E H 1426 4/72 1M <br />