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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; v 1601 E. Hazelton Ave. , Stockto.i, Calif. 4 <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Z2_ 3-73 <br /> (Complete In Triplicate) ZZ9�.0g0-pc� <br /> Application is 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB"ADDRESS/LOCATION.—_— CENSUS TRACT ' <br /> Owner's Name C1 Phone <br /> Address City`771 :rC:z - <br /> Contractor's Name ,� r-Y - ,-�' License # Phone ' N <br /> N � <br /> TYPE-OF WORK (Check)-_ NEW- WELL / / .-DEEPEN / / RECONDITION /7 DESTRUCTION /7 a <br /> PUMP INSTALLATION / PUMP REPAIR '/ / PUMP REP CEMENT _ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOQ 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 l <br /> Domestic/public Driven Gauge of Casing `„Yk <br /> Irrigation Gravel Pack Depth of Grout Seal 1 4 ' <br /> Other Rotary Type of Grout 1. <br /> Other Other Information " <br /> PUMP INSTALLATION: <br /> Contractor i <br /> Type of Pump cmc_ `.�_ H.P. ; <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> �,-DESTRUCTI.ON 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 /> �v �f <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F0 DEMT TENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTEAl <br /> D S ATE - . Z3 <br /> ADDITIONAL' COMMENTS: r <br /> PHASE II GROUT INSPECTION P III F INSPECTI!1M <br /> INSPECTION BY DATE INSPECT ATE 23- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 <br />