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V <br /> �� ,• <br /> ,10 <br /> . . .. , <br /> I+ SAN JOAQUIN,LOCAL 1!VA1,711 DISTRICT <br /> FOR OE'PIC USIi: 1601 E. Hazelton Ave. , StaCktu;,, Calif, <br /> .'' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. �7,- <br /> THIS <br /> -THIS PERMIT EXPIRES 1-YEAR FRO,: DATE ISSUED Date Issued 7 �� <br /> (Complete In Triplicate) q #; <br /> ApPlicatissq; is.hereby-tmade!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 /> 6 County-:Ordinance No.. 1862:•and °the.Rules:,and Regulations of- the San Joaquin Local Health District ' <br /> JOB AAAREsS/LOCATION _ '# <br /> •CENSUS TRACT . <br /> r <br /> Owner's-.Name. } <br /> Phone <br /> M <br /> Address. -eG,d , <br /> City <br /> r <br /> Contractor's Name ' ns.r.,..,�.; License # Phone lj6 6- ` 3 Y <br /> . ". `-g a TYPE OF WORK (Check): NEW WEI,-. /? DEEPS / UCONAITION /7 DESTRUCTION"f7 y� ' <br /> PUMP INSTALLATION ?U PUMP REPLACEMENT /7 <br /> 1 /�I .Ll�' REPAIR 17 <br /> i Other /_7 <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'PIT PRIVY <br /> SEWAGE DISPQ;:AL F�-ELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USEP M-1 ., ....�._ SPECIm',; <br /> CONSTRUCTION FICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> d Domestic/private Drilled <br /> Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gruvel Pp=_- Depth of Grout Seal <br /> Other Rotary Type of Grout ' <br /> - -- <br /> Other Other Information , ti <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> b` PUMP REPLACEMENT: <br /> / / State Work Doul. <br /> ;s PUMP REPAIR: /� State Work Done <br /> r IA�L_ <br /> i <br /> DESTRUCTION OF WELL: Well Diameterpproximate Depth <br /> ' Describe Material and Procedure j <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I ana the State of California pertaining to or regulating well construction. WithinfFIFTEEN RAYS <br /> titer comPletioi, of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLEE'RS REPORT of the well and notify them before pntting the well in use. Tine above <br /> :rk':ur;la[::ian iS true to the best of my knowledge and belief, � <br /> E 1 , <br /> ' TITLE <br /> (DRAW PIAT P ON REVERSE SIDE <br /> FOR DEPART IENT .USE 0_:LY <br /> ACCEPTED BY _ � /� DATE 7 <br /> i'I1,SL7 II GROUT INSPECTIO:y I'IIAS' III/F;NAL INSPECIZQ <br /> i_ DATE INSPECTION BY DATE, 7 � <br /> I;�SPFCTION PRIOR TO 1,'A0UT1N(G AND FINAL INSPECTIO <br /> 5/7.2 im C ; <br />