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SAN JOAQUIN LOCAL-1149ALTH DISTRICT <br /> _FO,%!OFFICE USE: 1601 E. Hazelton,.Ave;:, YSe68kton, Calif. <br /> Telephone; o,.,,(209)_466-6781 <br /> /7PLIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT, EXPIRES-!­iL,,'YEAR--TROM-DATE,ISSUED Date Issued <br /> (Complete'.In,--.Tr#licat&), <br /> Applicail:6ni is' hereby made to the San Joaquin-Loca.l,-::Heslth--:District for a-perm it toconstruct <br /> and/or install the work. hezein. described ,,. This applicati6ti-is made in compliance with San Joaquin <br /> County'br'dinance 'No 1862and-A the Rules and-,Regula tions.i"of the San Joaquin Local Health District. <br /> 0 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> 74V <br /> Owner's Name Phone <br /> Address city <br /> 40=� <br /> Contractor' License # 1791 Phone <br /> Z <br /> TYPE OF WORK (Check): -NEW WELL /7 DEEPENj-7RECONDITION /7 DESTRUCTION (7 <br /> PUMP INSTALLATION IZIPUMP REPAIR _7 PUMP REPLACEMENT`_ <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> , Domestic/privateDrilled Dia, of Well Casing <br /> Domestic/public , Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <br /> otection Rotary Type, of Grout' <br /> Disposal Other Qther information <br /> Geophysical 'Surface Seal Installed BY: <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. 7 77P <br /> PUNP' REPLACEMENT: State Work Done <br /> PUMA? '.REPAIR: /7 State Work Done <br /> ,RES.TRUCTION 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 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: I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO rROUTING ANA FINAL INSPECTION. . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN 0N -REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-BY c! ... .... DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOW": PHASE II FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E 1426 Rev. 1-74 1-74 2M.-,k--- <br />