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SAN JOAQUIN LOCAL UIEA.LTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktoi., Calif. <br /> Telephone: (209) 466-6781. <br /> O <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-- 111 a <br /> Eq'�7 X Y <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (� !i:�jj� CENSUS TRACT 00-5= 2io-t,& <br /> Owner's Name _ Phone <br /> Address 's- <br /> 0. City <br /> Contra: tor's Name ��# � ,!J License L-3Phone]'SCS-( <br /> TYPE OF WORK (Check) : NEW WELL/_ DEEPEN '/� RECONDITION /-7 DESTRUCTION /-7PUMP INSTALLATION / PUMP REPAIR '/—/ PUMP REPLACEMENT /? W <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK rh <br /> �Q R LIN S PIT PRIVY <br /> SEWAGE DISPOSAL F CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Keble T o V Dia. of Well Excavation / 1 fi <br /> _ -- )em-stic/private Drilled Dia. of Well Casing /6 1 � <br /> Domestic/public Driven Gauge of Casing J & <br /> Irrigation Gravel. ack� Depth of Grout Seal 5 p y <br /> Other Rot � Type of Grout,,, <br /> 0th r Other Information <br /> PUMP INSTALLATION: 'Contrac`tOr <br /> Type of 'u�mp - 1 H.P- "7 - <br /> PUMP REPLACEMENT: / / State Work Done <br />-.. PUMP-RE�AIR: / / 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- <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED 'M TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> f <br /> PHASE Ii FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY a �l DATE �`} � <br /> ADDITIONAL COMMENTS: <br /> 4 PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY rWDATE <br /> CALL�F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. e. <br /> E H 1426 4/72 1M <br />