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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. Hazelton tockton, Calif. <br /> FOTO OFFICE USE: Q� 1601 Ave. ,� <br /> Telephone: (209) 466-6781 Permit No77- /l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . <br /> THIS PERMIT EMPIRES I YEAR FROM DATE ISSUED, Date Issued 7 <br /> yU (Complete In Triplicate) <br /> Application 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 G, Lax !� 3"4"'e4c"� Al- U, -�g CENSUS TRACT <br /> 3�Y� � <br />' , X-Q— Phon7J7Owner s Name <br /> Address City <br /> C <br /> Contractor's Name License � �237 Phone�� <br /> I i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION f DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial -', " Cable Tool Dia. of Well Excavation <br /> Domestic/priate Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodictjiotection Rotary Type of Grout <br /> Disposal f ; Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION:. Contractor <br /> H.P. <br /> Type of mp <br /> Pu / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> 61 <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 /> t <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 b t of- my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI A F INSPE ON. <br /> SIGNEDTITLE <br /> PL T PLAN' ON REVERSE SIDE) - ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � DATES . <br /> ' APPLICATION ACCEPTED BY 4;? — <br /> ADDITIONAL COMMENTS: `'; <br /> PHASE II GROUT INSPECTION PHASE TII/FINAL INSPECTION <br /> N <br /> INSPECTION BY DATE INSPECTION BY /`f, _ _ DATE -, -` - I <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />