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SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , � tocktoh, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL• CONSTRUCTION OR PUMP PERMIT Permit No.-7-z-- 5 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued :!7 z <br /> (Complete In Triplicate) <br /> Application is -hereb made to the San Joaquin total 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 aid Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION - � z 2- _ .`. CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> City <br /> Address rQ �� <br /> � . <br /> Contractor's Name „ , License # 746: Z Phone <br /> ._. <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC ITANK _ 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 /> i Domestic/public. Driven Gauge of Casing Z 14 <br /> v. Irrigation Gravel Pack Depth of Grout Seal. " j-61 0 0 <br /> Other —V Rotary Type of Grout s <br /> t Other Other Information <br /> � •4 <br /> PUMP INSTALLATION_ Contractor <br /> -- Type o}}f Pump H.P. <br /> F <br /> ' PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> �Y 4 <br /> 1 ,DES_TRUCTION OF-WELL: Well Diameter Appkoximate Depth <br /> Describe Material-and Procedure <br /> I hereby agree to comply with all laws and regulations..of the San Joaquin LocalHealthDistrict <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 /> informati u to a beMmy know -dge, and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ._t.. DATE2fJ <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION- , PHASE •III/FINAL INSPECTION <br /> INSPECTION BY DATE w. = '. »I-NSPEGTION BY - - �- DATE-:=,,,, <br /> / zw <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND 'FINAL INSPECTION. <br /> j E H 1426 X6 ��""�'�„ ,L,�, 7/72 1M <br /> I <br />