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SAN JOAQUIN LOCAL HEALTH, DISTRICT- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,. StOcktan, Calif. , , <br /> Telephone :-__(209) 466-6781- , `> <br /> APPLICATION FOR•WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Zz- //*O"� <br /> THIS'�PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is -hereby mad 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 S Juin Local Health District. <br /> rReCTJOB,�9S/LOCATION Oy NSUS <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name rnige n S License UAU &Phone -� <br /> k TYPE OF WORK (Check) : NEW WELL./ DEEP / / + RECONDITION /—T DESTRUCTION /7 <br /> PUMP INST LLLLATION /� PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_IKS�2 -.. PIT PRIVY Q <br /> I SEWAGE DISPOSAL FIELD"— CESSPOOL/SEEPAGE PIT / OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,j( Cable Tool Dia, of Well Excavation 49; ' <br /> Domestic/private - Drilled Dia. of Well Casing 1 <br /> - (^ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �'� <br /> Other Rotary Type of Grout /fes 2 <br /> — Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> �Type- .o-f_RUMP i _ H.P.-_ <br /> PUMP REPLACEMENT: / / State Work Done - <br /> L <br /> PUMP 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 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 tr a to the best of my knowledge and belief. <br /> SIGNED TITLE �Ypry <br /> (DRAW PLOT PLAN ON REVERSE SIDE + <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI `�r � n ` ! � <br /> APPLICATION ACCEPTED BY W �(,� V DATE 1,2 b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL IN EC ION <br /> INSPECTION BY DATE INSPECTION B <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />