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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , St;ocktu , Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z 5 6 I � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 6- 13 7 Z <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 applicati m 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 /> - <br />' JOB ADDRESS/LOCATION �i' : <br /> _ 2 O D1P- -c50. 1/ ► I/C h/ CENSUS TRACT i <br /> Owner's Name _ I-Us2C'K' Tr A-J _,.. Phone <br /> Address Sig A.4C City ' 9SCRACAl <br /> -Gontravtor-J s Name 5 u T'To -J- f..je License # Phone '9,99-1-2o7 <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN -/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION {�/ PUMP REPAIR ,/ / PUMP REPLACEMENT J � <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 �Oj � a <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 C <br /> Other Rotary Type of Grout . <br /> Other Other Information7 <br /> PUMP INSTALLATION: Contractor 5 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /tate Work Dane !l G1.4cp VC TAJ1 <br /> PUMP REPAIR: / / State Work Done <br /> t <br /> ,PESTRUCTION_ 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 and belief. <br /> I <br /> SIGNED TITLE )t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> r--i <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I � <br /> APPLICATION ACCEPTED BY oma! DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G U IN ECTION PHASE/III/FIN6L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE •�e �3 _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />