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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stacktor., Calif. <br /> s.� <br /> Telephone: ' (209) 466-6781 0 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-_7 -7z/ <br /> ]�`� <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 <br /> m W, zwo CENSUS TRACT <br /> Owner's Name <br /> .k <br /> _ �f���'`� �R3�Q . ._..� Phone ' <br /> Address &U S2ag(6 j City �Ap . <br /> Contractor's Name !( License # Phone ' iS/vi7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /- <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of GroutAq <br /> Other Other Information - <br /> PUMP <br /> nformation PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> h <br /> PUMP REPAIR: / / State Work Done <br /> : Well Diameter <br /> PESTRUCTION OF WELLApproximate 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 /> informatio true to the best off my knowledge and belief. <br /> SIGNED e -Ei' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE -� <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE I I/FINAL INSPECTION` <br /> INSPECTION BY DATE ��_/ �� INSPECTION BY DATE <br /> .w <br /> CALF F'OR A 'G T INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 4/72 1MCr <br />