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SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,., Stotkton;' Cali ,{ <br /> 'Telephone: (209) 46&-6781 V �.p�� <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP RMIT Permit No 7 Z S 6 <br /> *. i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &-13. 71/ ' <br /> (Complete In Triplicate) <br /> Application is herebyzmade 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 <br /> �J &-tJ U CENSUS TRACT <br /> Owner's Name <br /> Phone ' ! <br /> Address _� � ' ----_ - Cit <br /> y <br /> Contractor's Name / 4 <br /> _...... _. � .w� License # -�� 3 Phone <br /> `TYPE-�OF'WORK' Check) �NEW:WELL"Y-"��. ""'' � DEEPENS_ <br /> ( I / /."^/,"RECOIVD�T-iOi�T�=/�=/•'=i3E�I'RiJCTiON <br /> PUMP INSTALLATION LF PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing } <br /> Irrigation Gravel Pack Depth of Grout Seal ^ <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> 0 <br /> PUMP INSTALLATION: Contractorm <br /> Type of Pump 14.P. 1 <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF"WELI; Well Diameter --` <br /> -_ 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 FIF'T'EEN 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 . r 7 TITLE <br /> (DRAW PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRA S III/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE.-�fd�*�1 .✓77'L <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />