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SAN JOAt UIN 'LOCALEIEALTH DISTRICT <br /> FOR OFFICE USE: 3.601 F. Hazelton Ave. , Stoc tt(.;.• , Calif. <br /> Telephoae: (209) 466-6-J,81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 z- D <br /> � F <br /> THIS PERMIT EXPIRES 1, YEAR FRO'Ml DATE ISSUED Date Issued •2-6`7L <br /> (Complete In Triplicate) <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 arid- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT 10 2` D-lam <br /> Owner's NameLG 4)?14 A C-11,/. 1I RAOL. .. Phone ' 4fj, Z <br /> i - <br /> f Address "t 01,0 A A (7 /Z City 3 TRAI e AGI. r <br /> Contractor's Name ikA1 1//_,VA S 1A L1'�.91<-- , / License #.2&15-7Q Phone '46 4/4 39 <br /> J�..._ - APL <br /> f TYPE OF WORK (Check) : NEW WELL 12/7 DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /� U <br /> PUMP INSTALLATION / J PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKS 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 i Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other - Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type l'rof Pump / Lcf - - H.P. i% <br /> PUMP REPLACEMENT: / / ,State Work Done <br /> PUMP REPAIR: 1 State Work Done <br /> ESTRUCTION 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEZ �� <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHAS9 III/FINAL INSPECTIOPT <br /> INSPECTION BY DATE INSPECTION EY DATE l` <br /> ff CALL FOR A GROUT INSPECTION PRIOR,TO GROUTING AND FINAL INSPECTION. <br /> k: E H 1G26 F 4/72 <br /> K � 1 <br />