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i <br /> •`' �4� � r • 5AN JOAQUIN LOCATE HEALTH DISTRICT <br /> FOR `OFFICE USE: 1601 E. Hazelton,--Ave. , Sto6-to , Calif. <br /> Telephone: ' (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -I3 '—[K ln/' <br /> THIS PERMIT EXPIRES 1 FEAR"FROM 'DATE 'ISSUED , Date Issued <br /> r _ . (Complete In Triplicate) . . <br /> Application is hereby made to the San Joaquin Vocal 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 176 CENSUS TRACT iA <br /> R <br /> Owner's Name <br /> Phone .V77- <br /> 7 ger F' <br /> PC� . . . ' <br /> N <br /> Address A(7, I City ;� e,cfro�e <br /> Contractor+s Name — T c�. l ►- License Phone <br /> �a S y1/��• <br /> TYPE..OF.�WORK-(Check) :,;,;,,NE.W_WELLF ...DEEPEN.//,�RECOND.ITTON_I_T DESTRUCTION_/ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> a <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC.!TANK _ SEWER LINES PIT PRIVY t <br /> SEWAGE'DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'j- Cable Tool Dia. of Well Excavation -f' 7. Z <br /> Domestic/private A Drilled Dia. of Well Casing Ar <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation ;1 Gravel Pack Depth of Grout Seal �n, r4 <br /> Other 11� , Rotary Type of Grout ' a cv <br /> 11 Other Other Information <br /> PUMP' INSTALLATION: f '~ <br /> Cn <br /> otractor �tt/�•e C, a <br /> Type of Pump Ar, _�b r,K H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />...;EESTRUC-T-ION-OF= W_E_LL:,::..�.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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � � DATE L �3 <br /> ADDITIONAL COMMENTS <br /> PHASE I GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BYi DATE INSPECTION BY DATE -?f f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL .INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br />