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SAN JOAQUIN LOCAL HEALTH DISTRICT A? <br /> FOR OFFICE USE: 1.601 E. <br /> Telephode-.i .­, (209).-466,- 6781 <br /> APPLICATION FOR WELL CONSTRUCTIJON:'_OR PUMP PERMIT Permit No. <br /> , <br /> THIS. PERMIT,,EXPIXES: l YEAR-':FROM DI�TE -ISSUED, Date Issued <br /> (Compl, 6te .ln',Triplicate) <br /> Application i8 hereby.- made�,to the: 5an .Ioaquiri:Loc­al H6alth District for a permit to construct <br /> and/or install the work herein described. This- applicafton, is made in compliance with San Joaquin ' <br /> County OrdinancecNo.- -1862,,an-'dithe.;Rule6'and Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's-Namef= <br /> Arc!" Phone 21K_2737 <br /> zzzzz-v <br /> Address 411_711�1 if�k City <br /> Contractor's Name License #� ,Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION j/R­PUMP PFPAIR '/—/-PUMP REPLACEMENT— /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /-00-/-" SEWER LINES PIT PRIVY <br /> SEWAGE DISPSAL ,FIELD CESSPOOL/SEEPAGE PIT ZZj OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . 612 <br /> Irrigation Gravel Pack Depth of Grout Seal � <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor d C_ <br /> Type of: Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP-REPAIR: State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describ'e Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local-, Health District <br /> and the State of California pertaining rtaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion o"fy work on 0 a new well, I will furnish the San Joaquin LocallHealth District a�` <br /> WELL DRILLERS RET' of the well and notify them before putting the well in use. The above <br /> information i, <br /> ,Vtrue to t �bes ,,of my knowledge. and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .kap. DATE %� <br /> ADDITIONAL COMMENTS; I <br /> PiT NSPECTION/ PHASE III/ INAL INSPECTION <br /> INSPECTION B� '�DA�E INSPECTION BY Z:A,� <br /> DATE <br /> CALL FOR <br /> GROUTSPECTI�N.PRIOR ,TO <br /> GROUTING'AND FINAL INSPECTION,. <br /> E H 1426 4/72 1M <br />