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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR <br /> jOFFICf USE: 1601 E. Hazel ton';AVe'.­_;Stoc!<tc-,j, Calif. <br /> Telephone: , .(209)"'.466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION',-OR PUMP PERMIT Permit No. <br /> THIS PERMIT, EXPIRES,,,l-'.YEAI(`; FROMADATE ISSUED Date Issued� <br /> t.'. .(Complete �Ifi` Triplicate) <br /> Applications, i:s).-herebyrmadey.to ;'the)San,Joaquin` Local Health Di-strict for a permit to construct <br /> and/or install the work herein described. Thi';,%agplicat�ion. is-made in; compliance with San Joa <br /> County,-Ond-inance-.-No-.-j 1862,,and,ith&1,Rules_' <br /> and.-Regulat1b.ns oflithe San quin Local Health Distri <br /> 'N <br /> JOB ADDRESS/LOCATION CENSUS TRACT,: <br /> Owner."s,Na'6_-I. Pb6nes22-5 <br /> 117 <br /> Address ; ry City <br /> Contracto'r*',Is Name <br /> License #o2t) IS-'Phones <br /> TYPE OF WORK (Check) : NEW WELL .0 DEEPEN RECONDITION /_7 DESTRUCTION 1-7 <br /> ­'PfJMP INSTALLATION -0 PUMP REPAIR PUMP REPLACEMENT-- ./-7-, <br /> Other a <br /> f i <br /> DISTANCE TO NEAREST: SEPTIC TANK"r <br /> r-��SEWER LINES PIT PRIVY <br /> SEWAGE DISPO.SAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> Gravel Pack Depth of Grout Seal <br /> Other/ Rotary Type of Grout lo <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 1 1.,LZ, L,- c� <br /> Type of Pump <br /> H.P. .I- <br /> PW,P REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION 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 DAY; <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT the well and notify them before putting the well in use. The above <br /> information is 10 th estjof my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID] <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> //) <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE- 11 GROUT INSPECTIO HA AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY/y <br /> DATE <br /> CALL FOR A GROUT INSPEC 1O .. <br /> _NP.RIOR .TO. GROUTING AND FINAL.I#i/CTON. <br /> H_ 1426 A/71 IV <br />