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in* , <br /> llftto <br /> SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , St ocktoa, .,Calif. � .. � r <br /> Telephone: (209) 466-•6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 'No. <br /> �Z. <br /> - THIS PERMIT EK�'IRES 1 REAR FP,OM DATE ISSUED ; Date Tssued <br /> S e+J' >g'uctG..lLfl r (Complete In Triplicate) 007-3(D is <br /> r <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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Sk'/PlR ©� CT�/!�/�/� �C�GIf �S,_ CENSUS TRACT <br /> Owner's Name Phone <br /> Address L®,az CA City 0 <br /> i Contradtor's Name — (,( 1�� �,t'�LL /!I/� )Pl!_MAS License # Z.2 ZZ Phone - <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / J RECONDITION /� DESTRUCTION 17 <br /> PUMP INSTALLATION /r PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL Fli�:b CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -t-- Cable Tool Dia. of Well Excavation /0-" Q <br /> omestic/private: Drilled`,'_. Dia. of Well Casing " _ N� <br /> Domestic/public Driven Gauge of Casing "/ <br /> _LGlrrigation Gravel Pack Depth. of Grout 'Seal <br /> Other Rotary- Type ` f Grout _ 41 sw Geewt _ <br /> Other i Other Information " <br /> PUMP INSTALLATION: Contractor + -- <br /> . Type of Pump I <br /> H.P. -2— <br /> PUNT <br /> —PUMP REPLACEMENT: I`-• ' <br /> �State`Work Done- <br /> PUMP REPAIR: / J. State Work Done <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 /> F <br /> SIGNED' TITLE _',QQ <br /> { <br /> DRAW PLOT PLAN ON REVERSE SID <br /> # FOR DEPARTMENT USE ONLY <br /> F PHASE I DATE 17-72-- <br /> APPLICATION ACCEPTED BY - <br /> f ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ �'CJ j DATE y•,1-7-1' INSPECTION BY DATE -72— <br /> ! CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H` 1426 <br />