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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktou, Calif. <br /> Telephone: .(209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2L--76_15 <br /> �HISPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' E ^!� . (Complete In Triplicate) <br /> Application is �;reb'.y 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 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION LU -' ENSUS TRACT <br /> Owner's Name - Phone <br /> Address 49 lvz:;p City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN /_7 RECONDITION / 7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 .PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 , <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 /> PUMP INSTALLATION: Contractor of �e -o7 <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: State Work Done !X <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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 be of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 71,? <br /> ADDITIONAL COMMENTS: ""7— <br /> PHASE II GROUT INSPECTION PHASE1 III FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E' H 1426- 4/72 1M <br /> f <br />