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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIgE USE: 1601 E. Hazelton Ave. , Stocktoi, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> t THIS PERMIT EXPIRES 1 YEAR FROM DATE_-ISSUED Date Issued <br /> l (Complete In Triplicate) <br /> Qt-7 1 <br /> � <br /> i ' 330 <br /> Application is ,he eby-made' to th6�.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 s <br /> County Ordinance.No...1862 and the Rules and Regulations -of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONI= house--�Nor�� sir?a 'ar17,;�;.r1T CENSUS TRACT <br /> Just east. of Lind home at 5117 E. Woodbridge Rd. <br /> Owner's Name - -Er1-V�,t- k Phone ' 3693396 <br /> Address --- --5111-E. Woo dbridge-_RAJ - - - -- --- ---- City �jX= <br /> Contractor's Name ry San Joaquin Pump Coe,, Inc,, License # 271300 Phone +369•-8471 } <br /> r: <br /> TYPE OF WORK (Check) : NEW WELL/yf DEEPEN '/—/ RECONDITION /7 DESTRUCTION /-T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT J� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY m <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial g Cable Tool Dia. of Well`Excavation Sa <br /> X Domestic/private Drilled Dia. of Well Casing r ^Rs <br /> Domestic/public Driven Gauge of Casing <br /> -lrriga-tion— = - Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information C1�. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> �. f <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 true to the best of my knowledge an elief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7J'"J� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 1162 DATE INSPECTION BY �- . DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E k 1426 4/72 1M <br />