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- = r) � . <br /> (➢� SAN JOAQUIN LOCAL HEALT."t <br /> r ''Ilk <br /> Q <br /> FOR OFFICE USE: 1601 E. Hazelton AV 781 <br /> Telephone: 9j {n� <br /> FOR WELL GO UCTIOP �`3P� FERMIPPy- <br /> APPLICATION <br /> D : ° Bate 'Issued t�f S-7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM` .1 p! <br /> (Compiete In � 1. <br /> ct <br /> Application is hereby made to 1hereindescribed.Joaquin Loca appllt4ition is_ made in�complancea permit twith nSan uJoaquin' <br /> and/or install the work hex <br /> Count Ordinance No. 1862 and -the Rules and Regulations of -the° San`Joaquin Local Health District. <br /> Y �- <br /> �� l CENSUS:TRACT ,•,__•,�..,,_._ <br /> sS LOCATIOl3 <br /> JOB ADDRE / �• �r— <br /> :.Phone -O _3�_ <br /> owner's Name <br /> 1 ;� .-- city <br /> Address <br /> € License #jG 3 73 Phon(j <br /> Contractor's Name - <br /> ORK Cheek): NEW WELL /—T DEEPEN /-7 RECONDITION. /-7 DESTRUCTION-/77— } <br /> TYPE QF"W PUMP•INSTALLATION /-7 PUMP REPAIR / /PUMP REPLACEMENT ' <br /> Other <br /> DISTANCE TO NEARE5T: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> I - ,B EWAGE' D.ISPOSAL. FIELD.— --� P <br /> -.-CESSPOOL/•SEEPAGE IT OTHER _ <br /> INTENDED USE TYPE OF WELL' <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial ;'�- Cable Tool Bia. of�Well Excavation. <br /> Dia. ofWellCasing <br /> Domestic/private t Drilled Gauge of Casing <br /> Domestic/public r <br /> xrigation.-- ._.._. . Gravel: Pack..':�.a� Bepth Mo. .'Grout Seal <br /> "" Other Rotary: Type of .Grout <br /> . Other .. Other Information <br /> y PUMP INSTALLATION: Contractor hJ'; H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> State Work Done�.LQ <br /> PUMP REPAIR: / / State Work-Done_ <br /> 3 <br /> p Approximate Depth- <br /> pESTRUCTION OF WELL: Well Diameter - <br /> ' Describe Material!and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a 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., REPORT of the well and- notify them before putting Che'well 'in use. The above <br /> ; information is to the best of my knowledge and belief. - <br /> r TITLE <br /> 1 SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR BEpALTMENT USE ONLY <br /> PHASE I s DATE �- <br /> -APPLICATION ACCEPTED BY <br /> ADDITIONAL CONMNTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE . 7R '7 <br /> , INSPECTION Bi2 DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION: 7/72 <br /> E H 1426 <br />