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f — <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Siockton, Calif. <br /> Telephone: . (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1'YEAR•-FROM DATE ISSUED 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 Joaquir <br /> ' County Ordinance No. 1862 and the Rules and Regulations .of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION ` C CENSUS TRACT <br /> Owner's Name 1.,A1F '4 A C1 r-AfPhone <br /> Address - - - . _ <br /> `,�/ �n.l - City �C"k7/rq� <br /> Contractor's Name �ti {1�Fr3 u - C�Q ,� _ License # �Z71?v/'O Phone <br /> TYPE OF WORK (Check): ANEW-WELL ,/,-T,� DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INST'ALLATION_`�/ PUMP REPAIR �PL�fP_REPLACEMENT �f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY *� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER G <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOM9kTC WELL <br /> INTENDED-USE MPH 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 z <br /> Irrigation ' _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r <br /> Disposal ' i Other Other Information <br /> Geophysical ` 'Surface Seal Installed BY•: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ?,-M�u� 5'c,6 +-.--fie -�Y7i,J ny O�- 7C_` <br /> � - * rkStateWo � 4PU `REE�IR: r <br /> P STRUCTION <br /> OF WELL: Diameter' Approximate Depth <br /> . DEscribefMater'ial arid-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 /> i 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-3'WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON,REVERSE SIDE ,. i <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I _ <br /> APPLICATION-ACCEPTED BY DATE 2,3 7S <br /> ADDITIONAL COMMENTS: . <br /> PHASE Il GROUT INSPECTION PHASINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7- r�� <br /> 4.. <br /> ,1 E S 1426 �. Rev. 1-74 1-74 2M' <br />