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r SAN JOAQUIN LOCAL IiLALTI7 7-IT-STRICT <br /> OFFICE USE: i6G1 E: Hazelton Ave. Stc}= : ' ., ; <br /> �� Calif, <br /> Telephone: . (209) 466-678I <br /> PPLICATION FOR WELL CONSTRUCTION OR PUMP PE-RXIT Permit No. <br /> THIS PERMIT: EXPIRES 1 YEAR FROM DATE .SSUED Date Issued Z Z Grl <br /> (Complete In Triplicate) <br /> Application isreby-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 Regulati-ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> -Owner's Name <br /> Phone l _3 Z 7� <br /> Address f <br /> City <br /> Contractor's Name License # <br /> 'hone� <br /> f/ Sl <br /> TYPE-OF-WORK-(Check).:,NEW-WELL .DEEPEN / /�-,RECONDITION /77ti-DESTRUCTION-/­-_7__.4 _ <br /> PUMP INSTALLATION "/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <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 SPECIFICATIONS <br /> Industrial V 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 /> 4' . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump,- H.P. / A <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:- / / State Work Done w <br />` TESTRUCTION OF WEL : Well Diameter x :. 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 /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY '` DATE -/-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F E III/FINAL INSPECTION <br /> INSPECTION BY DATE 7 2- INSPECTION BY DATE - <br /> A Z4 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING`AND FINAL INSPECTION. <br /> E H 1426 ' <br /> 41-7 2 1M `. <br />