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S�1N JO1CQ1xAQUI'N' LOCAL �IEALTY DTSTRICT -- <br /> K FOR OFFIME?USE: <br /> E. ga 'Califtop Hazelton ve <br /> �s <br /> F� Telephone (204) 466--:`6781 <br /> APPLICATION FOR WELL CONSTRUCTION •ORPUMP PERM' "{ ; "Permit''No, ' At <br /> i n s 707 .2 o u ry <br /> THIS PERMIT EXPIR$5 1 YEAR FROM.DAT.E ISSUED Date IssuedW <br /> (Comp!ete`,Tn Triplicate) <br /> Application 'is"here iy made``t'o theSan Joaquin Local Health Distrix <br /> and/or install for a permit to construct f <br /> the' work herein described, This application Pp n is made in compliance with San Joaquin <br /> County Ordinance Nb.' '1862 and the _ides and tRegulations of the Saiz Joaquin Local Health District. <br /> ` JOB ADDRESS/LOCATION . ' '. <br /> __M r 66 T . CENSUS TRACT <br /> Owner's Name .. - <br /> Phone <br /> Address 1z;t43 A). City "--.�CR ,� <br /> Contractor's Name 250 <br /> License # 0A Phone ,L� <br /> . MODES .. <br /> TYPE OF WORK (Check) : NEW WELL /�,/� DEEPEN '/ / RECONDITION /? DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / <br /> Otheri/7/ PUMP REPLACEMENT 1-7' <br /> r DISTANCE TO NEAREST: SEPTIC TANK ®® SEWER LINES a PIT PRIVY <br /> X SEWAGE ';DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial f Cable Tool Dia, of Well Excavation C <br /> Domestic/private 1 Drilled Dia. of Well Casing Al z.. <br /> Domestic/publicf Driven Gauge of Casing <br /> Irrigation ! X Gravel Pack Depth of Grout Seal <br /> Other v Rotary Type of Grout <br /> i f Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Zj ✓ g <br /> . / / State Work Done <br /> PUMP REPAIR: . <br /> r _ � /�/= State,Work-Done <br /> , ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local Health Di <br /> andthe 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 and belief, ` <br /> ti <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) .a <br /> FOI D TMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACC Y <br /> ADpITIONAL COMMENTS- DATE <br /> PHASE II GROUT 'INSPECTION P I INAL INSPECTION <br /> INSPECTION BY DATE INSPE TION BDATE <br /> t <br /> CALL FOR A GROUT, INSPECTION PRIOR TO GROUTING AND FINAL •INSPECTION. <br /> E H 1426 4/72 1M „;� <br />