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�-- � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockto- , Calif. 4 <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z L ' <br /> THIS PERMIT EXPIRES 1 YEAR "FROM. DATE 'ISSUED Dat�Isaued <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 San Joaquin <br /> County Ordinance No. 1.862 and{the Rules and Regulations of the San Joaquin Local- Health District. <br /> A <br /> JOB ADDRESS/LOCATION /�{/�L�_. R D CENSUS TRACT - <br /> Y-2- <br /> Owner's <br /> RACT 'YOwner's Name , /JCE iNj F- Phone <br /> Addressp 3 <br /> - --.�- -. _�-�---�}f�LL �®� � city <br /> Contractor's Name. - d R D License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /`/ DESTRUCTION /-7 <br /> PUMP INSTALL TION m/ / PUMP REPAID PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .�y'- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,Sp` CESSPOOL/SEEPAGE PIT Ze() OTHER /VQN;F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia. of Well Excavation Q <br /> Domestic/private Drilled Dia. of Well Casing COOµ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout i <br /> Other Other Information ' ' <br /> PUMP INSTALLATION: CoAmractor <br /> Type of-Pump,..- - ---- - --- - H.P. <br /> � r <br /> PUMP REPLACEMENT., / / State Work Done,,,. <br />:PUMP--REPAIR-:— - 5tate� Work Done— �.�,,.�. <br /> ,DESTRUCTION OF WELL: Weil 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 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 the well iii use. The above <br /> information is true o thebest of my knowledge 'and belief. i <br /> SIGNEDTITLE 1 3��,- <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMFATmFSE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPT --BY-- - D2;TE-S l� <br /> . ADDITIONAL COMMENTS: - <br /> --_ - --PHASE II�GROUT INSPECTION- �.�.-�.-ti-w _ FINAL:.INSPECTION- <br /> INSPECTION BY jjR 0 DATE INSPECTION BY U DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 iM '. <br />