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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fos;Of'PTCE USE: 1601 E. Hazelton Ave. , Stoc�ctan, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 SIJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _a2s-1S <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.workherein 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 /> JOB ADDRESS/LOCATION S CENSUS TRACT <br /> Owner's Name -�VSr OF= JFS7"_ FRAf(JC.O Phone 91�i <br /> Address Al�/r �_ 14VE— -- City SFKA) <br /> Contractor's Name License # Phone <br /> -TYPE OF WORK (Check}: NEW WELL/� DEEPEN /? RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /�] PUMP REPLACEMENT-" J <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ?r---- PROPERTY-LINE_. PRIVATE.-DOMESTIC-.WEI:I PUBLlC�DOMESTIC-WELL <br /> a. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 5 _ Industrial Cable Tool Dia. of Well Excavation I <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing CA <br /> Irrigation, Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal '` Other Other Information <br /> Geophysical Surface Seal Installed By: t <br /> i 'h � - <br /> PUMP INSTALLATION: Conamtractor , <br /> Typed1of 'Puvmp w -75 _ H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Do <br /> PUMP `.REPAIR: /_7 State Work Done <br /> STRUCTION OUWELL: Well Diameter Approximate Depth <br /> Desc ibe tenial and Proced <br /> 4 <br /> r_.tAtA444 061& <br /> I hereby agree Ito comply with 4a#11 laws and regulati ns of the San Joaquin Lo 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' fumish 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 WILX--CALL—FOR 'A 'GROUT tINSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ei6� Q � TITLE <br /> f : (DRAW PLOT PLAN ON REVERSE SIDE) �. <br /> I -�- - -- .-,- --F.OR_D d PARTMENT_.USE.-ONLY-- —"-"' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE T� <br /> E H 1426 Rev. 1-74 1-74 2M <br />