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? 4, <br /> -4 JOAQUIN LOCAL HEALTH D IS TRIC', <br /> USE 1601 E. Hazelton Ave. , 'Stackton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7-S-�Wl 72�0 <br /> THIS PERMIT EX PIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permi� to construct <br /> and/or install the work herein described. - This application is made in compliance with San J16aquit <br /> County Ordinance No. 1862 and the Rules andl,,R tions of the San Joaquin Local Health Dis�rict. <br /> 7_1 <br /> CENSUS TRACT <br /> JOB ADDRESSYLOCATION <br /> Owner's Name Phone <br /> Address city <br /> e' <br /> Contractor's Name License #)e'��3,73honede-6 �1_1 <br /> TYPE OF WORK (Check) : . NEW WELL DEEPEN RECONDITION DESTRUCTION /_7 <br /> PUMP INSTZLATION REPAIR _K—PUMP REPLACEME9T /_7 <br /> Other <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 Cable Tool Dia. of Well Excavation <br /> 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 /> PU�T INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PU�T REPLACE�ENT: State Work Done <br /> PU�T "',EPAIR: State Work Do <br /> OF WELL: Well Diameter rproximate]'.Dep-th <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws a-ad 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, I will 'furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REEPORT 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 /> SIGNED TITLE h, g:2�.aj&a) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTNENT,�M ONLY <br /> PdASE I <br /> APPLICATION ACCEPTED BY DATE, 1q.- 7 7 <br /> ADDITIONAL COIND1ENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FIN]AL INSPECTION <br /> INSPECTION BY DATE IfNSPECTION BY DATE J.- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />