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SAN JOAQUIN LOCAL; ITEALTU n7STRICTFOR OFFICE USE: 1.601 E. Hazelton Ave. , Stocktan, Calif. .,. <br /> Telephone': (209) 466-678' <br /> PLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. 7a- 5 5 0 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM "DATE ISSUED 'Date Issued 6-1 Z_7Z <br /> (Complete Ih-Ttiplicate) ; <br /> Application:.is'hereby­made`to the-:San Joaquin'-Local Health District fora permit to construct' <br /> and/or install the work herein described. This r; <br /> application ,made in compliance with San Joaquin <br /> County-Ordinance No. 1862 and the Rules-=and. Regulations -of °_the San Joaquin. Local Health Disti`rict. <br /> JOB ADDRESS/LOCATION 0 p " M CENSUS TRACT <br /> - <br /> :. f Phone <br /> i <br /> Address3__�.�/,.. <br /> - -. y it/ �I;�`... <br /> Cit <br /> Contractor's Name <br /> License # 26 L7&1 Phone 4.6cr993 9 <br /> TYPE OI' WORK (Check): NEW WELL /-7 DEEPEN /-" nCONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /�J PUMP REPAIR / /PUMP REPLACEMENT /7 <br /> 0they -- <br /> ..r <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 SPECIFICATION$ <br /> Industrial <br /> Cable Tool Dia. of -Well Excavation <br /> Domestic/priArate' Drilled Dia. of Well Casing ao. <br /> Domestic/public Driven . Gauge of Caaing ` <br /> Irrigation Gravel Pack Depth of Grout Seal - E <br /> Other Rotary . Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: . . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L_1 State Work Done <br /> PUMP REPAIR: / / State Work Done �ZJ�� �J��r,,,,�.�� <br /> 1 <br /> , ESTRUCTION OF!'WELL: Well Diameter _ _._... .__ Approximate Depth °. <br /> Describe Material and Procedure <br /> I he'reby.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 on a new well, I will furnish theiSan Joaquin Local. Health District a <br /> WELL DRILLERS�RT of the well and notify them before putting the well in use. The above <br /> information is true.- to th best of y knowledge and belief. <br /> SIGNED <br /> TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY05 _ DATE 6I <br /> Z <br /> _ . <br /> ADDITIONAL ..- <br /> COMMENTS., <br /> PHASE YI. GROUT.: INSPECTION FINAL ECT <br /> - ON _ . .... . ION i <br /> INSPECTION BYDATEINSPECTION BY E7? 17 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/.72 1M #� <br />