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AN JOAQUIN LOC+ L HEALTH DISTRICT <br /> t <br /> 0k OFFIi;E USE: ' x_601 E. Hazelton Ave. .'cc�c., ¢o".. Calif. <br /> Telephone: (20) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR L'aT, PERMIT Permit No. <br /> -� THIS PERMIT EXPIRES 1 YEAR F1101•1 DATE _SS"LIED 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 Joa uin Local Health District. <br /> �Y�o <br /> JOB ADDRESS/LOCATION J hm3 OG /'?Ib 4mr.4-1 jj�,{v v/,C CO/� ',l t ,?v y{4<,-may] CENSUS TRACT <br /> T�� G <br /> Owner's Name , CZ-1/ �'3`a- LLv z", b,)1 G-yPhone '3 5 3 1 ' T <br /> Addressr <br /> C Cy <br /> Contractor's Name -- -- . <br /> cO LO S -s Ph e <br /> -TYPE,OF-WORK=(Gheck-) . NEW WELL / J = DEEPENS/_/_ RECONDITION=/--7—-DESTRUCTION <br /> PUMP INSTALLATION j��PU.]P REPAIR "/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESO_OL/SEEPAGE PIT OTHER <br /> A <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 /> a7W. I <br /> PUMP" INSTALLATION: Contractor <br /> Type of Pump y2,�/nr S Z H.P. �!�A-[a a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> - i <br /> _2ESTRUCTION 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 FIFTEEI3 DAYS <br /> after c1pletion 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/hof my knowledge and belief. <br /> IA-SIGNEDv`' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMEN.10 USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS DATE <br /> ADDITIONAL COMMENTS._ i\j l T- <br /> PHASE II GROUT INSPECTION P II NAL INSPECTIO <br /> INSPECTION BY DATE INSPECT�`ON�Y DATE - ,cJ <br /> CALL FOR A GROUT.,INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />