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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stoc1-,.tt,n, Calif. <br /> s <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM TATE ISSUED , Date Issued Ij <br /> (Complete In Triplicate) �T <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 /> ,708 ADDRESS/LOCATION �QR/`f'J� z I#�� � -- _ CENSUS TRACT � �d <br /> Owner's Namef l/J Send �r'S - -_ - - - - Phone � r ' -ato r <br /> y <br /> Address S A- Q // atj-V,2city <br /> Contractor's Name License # // Phone 36 r3 '+F,3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /-7 DESTRUCTION / S f P/6� <br /> PUMP INSTALLATION / / PUMP REPAIR j / PUMP REPLACEMENT / <br /> Other I I <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 4 <br /> Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary - Type of Grout — 1 <br /> Other Other Information ' <br /> PUMP INSTALLATION: ContractorL&WAt .S <br /> Type of Pump f' / &"Alf H.P. 36 - - <br /> PUMP REPLACEMENT: / / State Work.Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure /,flF'S A4 Alizzy <br /> Cc� Llr Ct/i /¢ /9 C�:ve�2TT b/ll <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 /> informatio, is rue. to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /IIW _ DATE/, D <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />