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SAN JOAQUIN L HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton. ,.tT-Stockta:., Calif. <br /> Teleftone c; &' 9) 466=6781 7 Z !S <br /> APPLICATION FOR WELL CUr,TRUCTION OR PUMP PERMIT Permit No. `IZ-7� k1 <br /> v . <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued q- Z$-7v <br /> (Complete In'Triplicate') <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 made in compliance with San Joaquin . <br /> County Ordinance -No. 1862 an Llie Rules and-Regulations of the San JoaquinmLocal Health Di'stric.t6 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> .x,177? <br /> Owner's-Name' �'}'; Phone"' <br /> -� Q O <br /> Addresses - City <br /> Contractor's Name 22License 4�;: - 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION DESTRUCTION /7 <br /> PUMP INST CATION PUMP REPAIR/ /----PUMP REPLACEMENT Q <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY r k <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndustrial Cable Tool Dia. of Well Excavatiow) "lr1�_ <br /> omestic/private i Drilled Dia, of Well. Casing <br /> Domestic/public t Driven ,.?. Gauge of Casing <br /> Irrigation Gravel Pack*%'—s" Depth of Grout Seal - <br /> Other ( Rotary Type of Grout _ pwltz <br /> � 4 <br /> Other Other Informati n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, y <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> �t <br /> PUMP REPAIR: / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material grid=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 /> inform ion is ue, to the best of my knowledge and belief. <br /> SIGNE CC C! TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I // , <br /> x <br /> APPLICATION ACCEPTED BY �ylit/ , DATE 2 �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 3 DATE / 3n <br /> CALL FOR A GROUT INSPECTION PRIOR TO. GROUTING AND FINAL INSPE IO <br /> E H 1426 4/72 . 114 <br />