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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockt n, Calif. <br /> - k <br /> Telephone: . (209) 466--67!'81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72 4 7� <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM IODATE ISSUED Date Issued 2bL-jz_.)- <br /> (Complete In Triplic9te) ` <br /> Application is hereby`made'to tile' San`Joaquin 'Local Healtt!' District for a permit to construct <br /> and/or install the work herein described. This applicati&I is made' in compliance with San Joaquin <br /> E <br /> County Ordinance No. 1862 and- the- Rules -and'Regulations oElthe San Joaquin Local Health District. <br /> z: ;#,' <br /> JOB ADDRESS/LOCATION Lie 4 Az t!z CENSUS TRACT <br /> h <br /> Owner Name � '� Phone <br /> Address <br /> Contractor's Name License # Phone $. <br /> ff <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITI'ON /7 DESTRUCTION /7 <br /> PUMP INSLATION f / PUMP REPAIR / PUMP REPLACEMENT <br /> TAL <br /> Other l/ / <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 s Cable Tool Dia, of� Well Excavation �• <br /> Domestic/private Drilled Dia, of.-. Well Casing <br /> Domestic/public Driven Gauge oCasing <br /> •� <br />' /P f g _ 8 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 1 OtherOther Information. <br /> n <br /> Other 1 Rotary Type of+ Grout <br /> PUMP INSTALLATION: <br />` Cantr a' ctor <br /> Type of Pump H.P. <br />�( PUMP REPLACEMENT: / / State Work Done . <br /> PUMP�REPAIR: LV State Work Done <br /> M <br /> ,DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure j. <br /> I hereby agree to comply with all laws and regulations of �sthe San Joaquin Local Health District <br /> and the State •of California pertaining to or regulating we'll construction. Within FIFTEEN DAYS <br /> f after completion of my work on a new well, I will furnish'Jthe 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 /> SIGNEDTITLE ` <br /> (DRAW PLOT RLAN ON REVERSE SIDE) p <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l Q <br /> ! APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: :II: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL- INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Zj7DATE 2T <br /> CALL FOR A GROUT -INSPECTION-PRIOR TO .GROUTING AND FINAJ'- INSPECTION.- <br /> E H 1426 11. 7/72 1M <br />