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-SAN JOAQUIN LOCAL IjEAT„TH DIStRICT <br /> S ocktor Calif. 63 <br /> ;;AOR OFFICE USE: 1601 T. Hazelton Ave., ,t 7�� � <br /> Telephone (209}.`4666781 _ <br /> APPLICATION FOR WELL CONSTRUCTION- OR PUMP PERMIT Permit No. 75 ' Sh y� I <br /> THIS PERMIT -EXPIRES l YEAR-FROM DATE ISSUED Date Issued <br /> r. .(Cowplete. InTriplicate) I' <br /> Application,:is hereby-made.to the-. San.,Jbaquin..Loca1''Health District for a permit to construct ' <br /> and/or install the work herein described. This- application is -made in compliance ujrjh San Joaquin <br /> County .Ordinance .No-. 1862 and 'the--Rulesljan&i Regulations of- the.San Joaquin Local'Health District. <br /> 10 a kr�' �..s {- "s y 0 <br /> JOB ADDRESS/LOCATION !L� CENSUS TRACT ' r <br /> z �.�..f 3t ,1a a c, <br /> Of <br /> Owner's Named " Phone 23 <br /> Address City ' <br /> ..�'... .. ..: .. `/ . .. ,_ . License �� � Phone <br /> Contractor s Name dIC�G I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / . RECONDITION /_ DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSE IIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k <br /> Industrial Cable Tool Dia. of Well Excavation �d <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ 12=n9� N) <br /> Irrigation G 1 Pack Depth of Grout Seal [J <br /> Other § Rotary Type of Grout <br /> ;- Other Other Information' <br /> PUMP­�NSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done. -- <br /> E PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF �.WELL: Well Diameter Approximate Depth <br /> I Describe Material and rrocedure <br /> I hereby agxeeto•.comply with all laws- and regulations of the San Joaquin Local Health District <br /> and the State of Califo a pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of y work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS T of the well and notify them before putting the well in use. The above <br /> information ue to the best of my/knowledge and belief. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SID 1 <br /> R DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION jACCEPTED B DATEADDITIONAL TS: OU INSPECTIO PHASR7 I INAZ INSPECTI INSPECTION DATE i INSPECTION $ ,� 4,1 DATE <br /> CALL FOROUT INSPECTION,,pRI TO, ROUTING AND .FINAL INS ECTION- <br /> E H 1426 4/72 1M <br />