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/ - = <br /> [/ S�M JOAQU3N LOCAL F-Er.ALT?x DTSTZICT. <br /> FOR OFFICE USE: I601 E. Hazelton Ave. +toc�.�<:+ Calif. <br /> Telephone: (209' 46' --ilii l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM= Permit No. 72-t�9� <br /> r 73- _V_// <br /> THIS PERMIT EXPIRES 1 YEAR FR,0,M DATt"' ".SSUED ; Date Issued <br /> '(Complete In Triplicate) -��� <br /> Application is hereby made -to the. San Joaquin Local� Health District fora 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 CENSUS TRACT <br /> Owner's Name( _ II�C��c� Phone ' <br /> Address C� ��i . C­�� T City ' <br /> Contractor's Name License <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION & DESTRUCTION /_ <br /> �. PUMP INSTAL/_/LATION � PUr4P REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / �I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 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 OtheP Information ' <br /> r �} <br /> PUMP INSTALLATION: Contractor" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done l�c/W/.Z <br /> f <br /> f ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> f <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 REPO of the well and notify them before putting the well in use. The above <br /> information is ue o t t of m knowledge and belief. <br /> r SIGNED d-r TITL <br /> r <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> ( FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' i 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT109 PHASE II /FINAL INSPECTION <br /> G INSPECTION BY DATE INSPECTION BY DATE <br /> f CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. +�` l <br /> E H 1426 4/72 1M <br />