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r F <br /> f� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , StockL-at,, Calif. <br /> . Telephone: (209)`466-6781 <br /> tAPPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. _- 73 THIS PERMIT•.MIRES 1 .YEARFROM DATE=ISSUED Date Issued(Complete In•'Triplicate)` c <br /> Application -is-.hereby .madesto the- San Zoaquin 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 df,the San 'Joaquin Local-Health -District. <br /> •{.,K :.. ., w >:2375'/ fit: I�ARiPos�9 <br /> JOB ADDRESS/LOCATION Ry'ry)'Lt�p W .. 0-yi CENSUS TRACT . <br /> Owner!s Name Phone - <br /> Address 13 S of City <br /> Contractor's Name 0 P. W9110 License # 282 Phone <br /> Fs_3 j--7_ <br /> TYPE OF WORK (Check) : NEW WELL- / / DEEPEN RECONDITION /_7 DESTRUCTION /_7 y� <br /> PUMP INSTTLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other: / / <br /> DISTANCE TO NEAREST: SEPTIC TANK jea 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 07" w <br /> Domestic/public Driven Gauge of!Casing - X�0_ $00— g Za WZZ-ZI. <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 /> 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 well in use. The above <br /> information is true to. the best of .my knowledge and belief. <br /> SIGNED TITLE &AU4 <br /> (DRAW PLOT YLAN ON REVERSE SIDE) <br /> MFORPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED B f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I WOUT INSPECTION PHAS T/FINAL INSPEC N <br /> INSPECTION BY 4 DATE --6- INSPECTION BY DATE ZO ` <br /> CALL FOR A GROUT._INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426 4/72 1M <br />