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-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 ICE E: 1601 E. Hazelton Ave; , StbEkton, Calif. <br /> Telephone : J209) 466--6781 7`Z-5 Geo <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 0'>i Gni CENSUS TRACT <br /> Owner's Name �,r r <br /> Phone 4eg4(- /b <br /> Address 3 `_ 5 eer <br /> City <br /> Contractor's Name License Phone 4,,77-1�'r" <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <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 w, <br /> Domestic/private Drilled Dia. of Well Casing ca ° { <br /> Domestic/public Driven Gauge of Casing iZ- , <br /> Irrigation Gravel Pack Depth of Grout Seal g`6` <br /> OtherRotar <br /> y Type of,Grout <br /> Other Other Information { <br /> t <br /> i <br /> PUMP INSTALLATION Contractor � y ,2G s-7 <br /> Type of Pump - ..,, ...._ _ H.P. <br /> ' <br /> �— a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter a <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 FIFTEEN DAYS Y, <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <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 �.i. E'e <br /> �c TITLE <br /> �DILOT _LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE Al -7 2 __ <br /> ADDITIONAL COMMENTS: l <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY E 1 , DATE T-,7,f _ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 7/72 1M e <br />