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LJ <br /> SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFjC-E�S,E: 1601 E. Hazelton Ave. , Stockm-, Calif. <br /> Telephone: (209) .466--6781 <br /> APPLICATION FOR WELL CONSTRJCTION OR PUNT PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSI7ED Date Issued <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (j / CENSUS TRACT <br /> Owner's Name PPhone q(r,�! <br /> Address , D /- City <br /> Contractor's Name P4 9 License i Phone 9 t <br /> TYPE OF WORK (Check) : NEW WELL /�EPEN /-7 RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION`/�z4-�UMP .REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,-- - FEWER LINES C) --t—rIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,�7-,12 CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF I,ELL CONSTRUCTION SPECIFICATIONS <br /> Ind strial Cable Tool Dia. of .Well Excavation <br /> omes tic/private Dri�Ied bia. o"f Well Casing <br /> Domestic/public Driven Gauge of Casing /L7 <br /> Irrigation Gravel Pack Depth of Grout S 1 <— 0Tn�j,�►.�r �ZQ_ <br /> Other Mary Type of Grout y i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 3 - �- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PT-MP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 Joagb-in 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 /> inform 'on is true to the t o y knowledge and belief. <br /> SIGNED �• TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 7 <br /> 'HAS E I / <br /> 7 <br /> APPL CEPTED BY DATE <br /> 'ITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY _ DATE \-a f3-l� INSPECTION BY ►ti, DATE <br /> R <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 4/72 1M <br />