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! t?' SAN'�AQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 I1•, Azelton Ave. , Stocktoi., Calif. k <br /> Telephone: (209) 466-678i <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1::�' _ <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> rLication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ./or install the work herein described. This application is made in compliance with San Joaquin <br /> inty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F7 ) ' \(-, c )i' /` I) <br /> CENS�S T <br /> RACT6 ADDRESS/LOCATION <br /> Fr's Name / ., /• ! r. �' f( r ��r�. f� Phone <br /> tress i _I - "1 —4 �-/' <br /> -- .L. City [ <br /> F--ractor's Name ell fl C, License 11 I // ,' Phone .? r <br /> OF WORK (Check) : NEW WELL_ DEEPEN RECONDITION _ DESTRUCTION _7 <br /> Ii PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT. /7 <br /> Other / / <br /> FIANCE 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 Cable Tool Dia. of Well Excavation <br /> f 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 /> IP INSTALLATION: Contractor r <br /> Type of Pump .r. H.P. <br /> IF REPLACEMENT: / / State .Work Done <br /> F' REPAIR: /�/ State Work Done <br /> CRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Lereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ithe State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r completion of my work on a new well, Z wiT7 furnish the San Joaquin Local Health District a. <br /> .L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ' rmation is true to the/best of my knowledge and belief. <br /> i <br /> �NED --/J/I < , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY . <br /> ?LICATION ACCEPTED BY DATE SZ22 <br /> TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL .INSPECTION <br /> . irECTION BY DATE INSPECTION BY DATE <br /> F.ALL FOR A GROUT INSPECTION.:PRIOR TO GROUTING'AND FINAL INSPECTION: ' <br /> Is H 1426 4/72 1M <br />