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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR<OFFICE USE: 1601 E. HazeltonAve.,, StockLor., Calif. 7 L-! 7 LlJ <br /> Telephone: .' (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. ZZ117 R <br /> THIS PERMIT AXI'°IRES- I YEAR FROM,DATE ISSUED " ' Date Issued -ZS~ � <br /> (Complete In Triplicate) <br /> Application is here y made--to the.:-San-,Joaquin- Loc-al Health District° for a permit Co construct <br /> and/or install the work herein described. This application is ,made it- <br /> compliance-County Ordinance No.411862-.and,the Re nd. Regulations of the San Joaquin Local Health�District. <br /> CENSUS; TRACT <br /> JOB ADDRESS/LOCATION - .x{777 F 7 <br /> Phone - <e zg412 l <br /> Owner's Name" <br /> Motel ❑Other --------------------------------- ------ <br /> � ----- --- -� - .. _ ....L...« ..F L-..,.1......,.,� t--rhnna rrinr4ar 1 <br /> License � rf c <br /> Contractor s Name v .m <br /> TYPE OF WORK (Check) : NEW WELL I17I DEEPENSTRUCTION f7 <br /> RECONDITION <br /> PAIR;/N Pt7MPEREPLACEMEWT 17 � <br /> PUMP INSTALLATION /V/ PUMP ti9 <br /> { <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD...__-. -,CESSPOOL/SEEPAGE PIT OTHER <br /> 4' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial.. 1 Cable Tool Dia. of Well Excavation 4 '' <br /> }/ Domestic/private Drilled Dia. of Well Casing n.+ <br /> Domestic/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 /> 1 - ' <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> ' PUMP REPLACEMENT: / / <br /> State Work',Done <br /> PUMP REPAIR: / / " State Work Donet # <br /> f Y <br /> I Approximate Depth <br /> ,DESTRUCTION OF WELL: We11�Diameter <br /> DescribeiMaterial and Procedure <br /> I hereby agree to comply withAall laws and regulations of the San Joaquin Local Health District <br /> Within FIFTEEN DAYS <br /> istrict <br /> and the State of California pertaining to or'regulating well construction. <br /> after' completion of my work on a new well, I will furnish the San Joaquin Local Health Dct 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 /> y u <br /> TITLEp`�� <br /> k SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: USE FINAL INSPECT N <br /> PHASE I GROUT INSPECTION _ y -INSPECTION BY DATE/U X <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INS ACTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />