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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stocktoa, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> /�js � 1��,s�,�f,^Q �1 ,rsr /e"i CENSUS TRACT <br /> Owner's Name . . Phone <br /> Address City Arc-,,1 -i <br /> Contractor's Name �it1,rJ,,� lit f G/ , � � �.�C License # X o 7G/ Phone Xe',X LL. <br /> TYPE 0 WORk Check) : NEW WELL/ / DEEPEN '/_7 RECONDI ON / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAI PUMP REPLACEMENT /XT <br /> i Other J / TA V 1 <br /> D AN NEAREST: SEPTIC TANK . SE NES PI <br /> SEWAGE DISPOS�FIELD C SPOOL S EP GE OTHER <br /> INTENDED USE TYPE OF WELL 4ONSTIUCTION SPECIFICATIONS <br /> Industrial Cable Toon Dia f 11 1xcavation <br /> Domestic/private Drilled D'a W 11 Casing <br /> Domestic/public Driven f au; f sing <br /> >c' Irrigation Gravel f G out Seal <br /> Other Rotary pe of Grout <br /> t her Information ' <br /> PUMP INSTALLATION: ntractor /f/ 1 r "� ki C" <br /> r> T e of P _ .777eFiet" H.P. <br /> PUMP REPLACEMENT: Work Done `/ <br /> PUMP REPAIR: / / State Work Dane <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T Describe Material and Procedure t <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, V 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. i <br /> SIGNED -r� �x-�-t � �'� �.� cTITLE - Vc� c'%�_V:­e, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY , <br /> PHASE T <br /> APPLICATION ACCEPTED BY ' t � DATE ��- <br /> ADDITIONAL COMMENTS: r� <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL_ FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />