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5 <br /> SAN JOAQUIN LOCAL.. 13EALTH DISTRICT f <br /> FOR OFFICE USE: 1601 E. Haze!tori-'Av.6 S�oc�kton, Calif. <br /> Telephone:.: . .(209)Y1466=-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION:.OR PUMP PERMIT Permit No. 5__346) <br /> THIS PERMIT EXPIRES' l-YEAR 'FROM -DATE •ISSUED- r Date Issued //_. L/J-1-- <br /> •a.�- -, '{Complete In Triplicate} <br /> Applicationt...is :hereby-.made•sto the_San:;Joaquin•Local• health District for a permit to construct <br /> and/or install the work herein described. _This',appl,ication is made in compliance with San Joaquin . <br /> County r Ordinance c.NO,c1862r'andttheFRules and s-Regulations-Uof 'the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r.''CENSUS:'TRACT <br /> b <br /> ,���'l sfs::•"2:i =; l w.,�s.��'�7�', .`! �'�,!-:tLf �T � i.� C',� ,. a max.,. - a <br /> Owner:s Name 01 Phone. �,., �`�3 <br /> Address p v <br /> bt <br /> City <br /> Contractor's Name a�� � License # /.26 ya Phone <br /> TYPE OF'WORK (Check): NEW WELL""//--DEEPEN' / / -R•ECOND-ITION/_/:.DESTRUC;T-ION_./_�.--:..___ . <br /> PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 T� <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 K . Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing it A `LL. <br /> Domestic/public Driven Gauge- of Casing Q <br /> X . Irrigation Gravel Pack Depth: of Grout Seal Q j <br /> Other Rotary Type of Grout <br /> 1 .Other "^' "" Other"Information <br /> yy <br /> PUMP INSTALLATION: Contractor F <br /> Type.,6f, Pump H.P. <br /> PUMP REPLACEMENT: .r-. / / State Work Done <br /> t <br /> PUMP REPAIR: ~ 1. Sate Work Done <br /> - <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 best of my knowledge and belief. <br /> SIGNED <br /> 'z <br /> i ty TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,. <br /> APPLICATION ACCEPTED BY DATE ZZ-2-1- <br /> ADDITIONAL <br /> - �. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I / NAL INSPECTION <br /> INSPECTION BY DATE INSPE ON BX DATE <br /> CALL FOR A GROUT INSPECTION.,,PRIOR-,.TO=GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172 IM �_ <br />