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/,t tg SAN JOAQUIN LOCAL HEAI.TDTST_R.1CT <br /> -TOR—OFFICEUSE: 1.601 11.. Hazelton Ave. , St1(­-_­.-L..:;4- , Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUYvP 'PET011T Permit No.7?-- :35) <br /> qq -70 <br /> g- 7 7, <br /> THIS -PERMIT EXPIRES I YEAR FP\01-, 1,LSISUED Date Issued <br /> (Complete Iri Triplicate) <br /> Application is hereby made to -the San Joaquin Local Health District for a permit to construct <br /> 44 <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 141 V64 � /Cc-in-__ CENSUS TRACT <br /> Owner's Name Phone <br /> lip <br /> Address �City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /_7 DESTRUCTION /7 -7 <br /> /L A <br /> PUMP INSTAL ION PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> Z; ; 6z.,&1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPIT 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other" Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP -REPAIR:— State Work Done <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 tr to th be ' 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 <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION 7 <br /> _Zr <br /> INSPECTION BY & DATE INSPECTION BY J PAT!; <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E R 1426 <br />