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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR OFFICE USE: VW11601 E. Hazelton Ave. , Stocktot,; Calif. <br /> Telephone: (205) 466-6781 .- <br /> APPLICATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No. 7,) --3f3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED : Date Issued - -4-7z <br /> (Complete In Triplicate) <br /> Applicationis 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 aria the Rules and Regulations of the San Joaquin Local Health District. <br /> i3 JOB ADDRESS/LOCATION CENSUS TRACT 05V-0`f!i <br />! <br /> Owner's Name s� .59/3 <br />� Phone � <br /> E. <br /> k Address � City <br /> Contractor's Name -� - p> License # Phone (� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / /`—RECONDTION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMA' REPAIR J 7_PUMP REPLACEMENT /`T <br /> Other,l f / <br /> DISTANCE TO DEAREST: SEPTIC ,'TANK SEWER LINES PIT PRIVY <br /> SEWAGE :DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 i. <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 1_._-___ Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout T <br />} 1 Other Other Information ' i <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done E <br /> t � <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 i <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 Au�� TITLE <br /> (DRAW PLOT PLAN WN REVERSE SIDE) <br /> PHASE 'I OR DEPARTMENT USE ONLY 3 <br /> APPLICATION ACCEPTED BY DATE ' L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT.INSPECTION PHASE II FIN CINSPECTI <br /> INSPECTION BY� DATE INSPECTION BY DATE 7 `J <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 � 1M <br /> r <br />