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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktou, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 Z_ y ?- <br /> 'TY <br /> 'TY 7 3 f <br /> THIS PERMIT EXPIRES 1 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 San Joaquin ", <br /> County Ordinance No. 1862 and the Rules and Regulations sof the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI X �D lt�.r CENSUS TRACT <br /> Owner's -N <br /> Phone <br /> Address o Cityr " <br /> Contractor's Name V-y t�I( Lice se � L Ph�on 3 <br /> TYPE Oki WORK (Check) : NEW WELL A7 DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION R17 PUMP REPAIR/ / PUMP REPLACEMENT /? !I <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK " <br /> /Q SEWER LINES / PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /Z= OTHER moi , <br /> O <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 /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S LL-LS I?? / /G H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well 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 a <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 in use. The above <br /> informatio/n� is true to the best of my knowledge and belief. <br /> SIGNED TITLE Y II <br /> (DRAW PLOT PLAN ON REVERSE SID—ET! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Iotz <br /> APPLICATION ACCEPTED BY T DATE X-/6 - 7.2- £ <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E S- ;L6.77- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. (4) <br /> L H 1426 4/72 1M <br />