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SAN JOAQUIN LOCAL HEALTH DISTRICT M <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , •St-ockton, Calif. I <br /> .. <br /> Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � � <br /> THIS PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued Z�-��T� <br /> (Complete In Triplicate)' <br /> Application is hereby made to the San Joaquin Local Health Districd� inrcomplianceermit tconstruct <br /> pP <br /> withSanJoaquin <br /> and/or install the work herein described. This application s <br /> County Ordinance No. 1862 ' R} s and Regulations of the San Jo <br /> in Local Health District. i <br /> ENSUS TRACT <br /> JOB ADDRESS/LOCATION 1t� - <br /> �� l Wt� _ %' tl✓' E r I <br /> (timer's Name Phone <br /> Address a <br /> r S City S Q� <br /> �� �' License 4� � G�j_? Phone �,7 <br /> Contractor's Name ` <br /> t <br /> TYPE OF WORK (Check) : NEW WELL /� -DEEPEN /p pCROEPAIRI/N// P�EREPLACEMENT /_7AL <br /> PUMP INSTLATION / <br /> Other' / / <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC ISPOSAL FIELD ER LINE CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE <br /> fCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE :TYPE OF WELL <br /> Industrial t Cable Tool Dia. of Well Excavation r <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation f Gravel Pack Depth of Grout Seal <br /> I Rotary -Type- of Grout-� < <br /> Other .; �,..�.. -� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor != <br /> Type(of Pump -= . . H.P. <br /> PUMP REPLACEMENT; State Work Done _ <br /> PUMP REPAIR: <br /> State Work Done <br /> ,)ESTRUCTION OF WELL: -Well Diameter <br /> 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 n€ the well and notify them before putting the well in use. The above <br /> information is true to the best o my knowledge and belief- <br /> TITLE--TITLE-- r <br /> I SIGNED... <br /> W., . (DRAW PLOT PLAN .ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I DATE <br /> I APPLICATION ACCEPTED BY <br /> ADDITIONAL -60MJiENTS: / /D .yam. P SE II FINAL INSPECTIO <br /> PHASE II G OUT INSPECTION INSPECTION BY DATE i/ /0 v <br /> f INSPECTION BY �P_ DATE i f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. 7/72 IM <br /> E H 1426 <br />