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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U:E: 1601 E. 'Hazelton Ave.-, Stockto:a, Calif. <br /> Telephone (209) ; 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L-5 L3 <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued L 7Z- <br /> (Complete <br /> L(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 ) Q W Wt t4-06_ CENSUS TRACT <br /> Owner's Name W;l L L 1 Phone 95/' <br /> Address z Wttj 1 r L,ator: City <br /> II �� jj _ I r q-_ � <br /> Contractor's Name C L } 2( W f � G (� IP DC7 , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/ J RECONDITION /_7 DESTRUCTION 67 <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 /> O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation (Q <br /> Domestic/private Drilled Dia. of Well Casing IVO-V E <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter & Approximate Depth 7b F7` <br /> Describe Material and Procedure _ �/Zc7(4,-r <br /> w� <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 /> informati ue to the best of my knowledge and belief. <br /> SIGNED TITLE .� r✓r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 4/72 1M <br />