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g / SAN JOAQUIN LOCAL HEALTH DISTRICT /zm <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 5tock.ton; Calif. <br /> Telephone: (209) 466-6181 <br /> 1ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED ; Date Issued A -I-77/ <br /> T (Complete In Tripli6ate) <br /> Application is hereb 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 with San Joaquin <br /> County Ordinance No." 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 41 <br /> JOB ADDRESS/LOCATION .�3 sf. CENSUS TRACT <br /> Owner's, Name � -y ����ry ���i _ Phone <br /> Address S Cit <br /> Contractor's Name <br /> I,-- License #a147Phone <br /> TYPE OF WORK (Check) : NEW WELL /rT DEEPEN '/—/ RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT 1,,� r„ <br /> Other <br /> DISTANCE, TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 3 <br /> INTENDED'USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ;i Drilled Dia. of Well Casing <br /> Doimestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �^ <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> t � <br /> PUMP INSTALLATION: Contractor �f <br /> Type of Pump gy H.P. �4� <br /> i <br /> PUMP REPLACEMENT: / / State'Work Done - <br /> 4 \ r <br /> f � I <br /> F PUMP REPAIR: / / 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-wel in use. The above <br /> informatio is tr :, tlthe bestt of my kn6wledge andbelief.ER <br /> SIGNED L- TITLE <br /> (DRAW PLOT PLAN ON REV] SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY1[:72 <br /> — —�. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 1M <br />