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�_vo4A�_."RUIN- --MAL HEALTH DISTR.. <br /> ►!Of. OFFICL USE: 1bp1 E. Hazelton Ave. , Stocieton, C �y � <br /> . _ <br /> Telephone:p (209) .466-6781 �. <br /> r--- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP E Oe"rma t No. 73 3// <br /> THIS PERMIT EXPIRES 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 permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with Sart Joaquin <br /> County Ordinance: No. 1862 and the Rules and .Regulations of the San Joaquin Local Health Disgrict. <br /> JOB ADDRESS/LOCATION <br /> CENSUS 'TRACT <br /> Owner's Name C iii / <br /> Phone <br /> Address Cityc �la <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/_% RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP -REPAIR / / PUMP REPLACEMENT <br /> E Other /T/ <br /> DISTANCE TO NEAREST: SEPTIC TAiNK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,` Cable Tool Dia. of Well Excavation ! <br /> Domestic/private T <br /> /p 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 /�erl - <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor eL_G <br /> T Type of Pump H.P. r� <br /> PLMP REPLACEMENT: / / State Work Done <br /> PUMP 'PAIR. / / State Work Done <br /> DF4�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 DAYS <br /> after completion of my work a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of,tit'e Yell, and notify them before putting the well in use. The above <br /> information is true do the best of my knowledgejand belief. <br /> SIGNED c-- r " -" TITLE .y <br /> (MW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> Pi1ASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL C010KGNTS: <br /> PHASE II GROUT INSPECTION P SE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BYDATE / l <br /> CALL POR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E R 1426 K/71im <br />