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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 5t6ckton, Calif, <br /> r Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. <br /> Cid <br /> THIS PERMIT EXPIRES I YEAR FROM DATE' ISSUED pY• <br /> Date Issued �•�Zi <br /> I (Complete In Triplicate) 7 %Lf3_ Zgrn -p <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 wade in compliance with San Joaquirf <br /> County Ordinance�No.>,1862 .and.the. Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 77T �f �F orf ,p CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address; p <br /> 11110 <br /> '5N <br /> Contractor's <br /> -' <br /> � City S <br />! Contractor's Name E�tlA/lx% <br /> G� License # JM4�Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN RECONDITION /_7 DESTRUCTION /� <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: 5EPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL :FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ..CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge-of;Casiiig-`­` _ /, - ' f <br /> Irrigation _)(' Gravel Pack Depth of Grout Seal <br /> Other Rotary —-- �� <br /> - ••— _.....�.._ Y of Grout <br /> Other Other Information — <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. � <br /> PUMP REPLACEMENT: / / State Work Done V1 <br /> PUMP REPAIR: / / .State Work Done 4 <br />,DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth y <br /> Describe Material and Procedure <br /> I hereby agree to comply with `aZl laws and regulations of the San - <br /> cal 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 <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 /> f <br /> SIGNED <br /> TITLE <br /> W LAN ON REVERSE SIDE <br /> PHASE I <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: DATE _ v <br /> PHASE II G 0 N E N PHASE N <br /> III FINAL INSPECTITIO <br /> INSPECTION BY DATE " _ - 2� INSPECTION BY DATE N 7Z <br /> CALL FOR A OUT INSPECTION''PRIOR TO GROUTING AND FINAL INS TION <br /> E H 1426 . 7/72 1M <br />