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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. ,HE , <br /> Calif. <br /> v► f9M Telephone: (209) 466-6781 a <br /> s APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3/ <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 fora permit to construct <br /> and/or 'install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> e <br /> JOB ADDRESS/LOCATION CENSUS TRACT I <br /> Owner's Name , ' Phone <br /> Address a City <br /> Contractor's Name License GZ ?Phone Qf� <br /> 1S-r: k�Lt f <br /> TYPE OF WORK (Check): NEW G3ELL DEEPEN-{/��/��REGONDITIQN' / / DESTRUCTION /� <br /> PUMP INSTAAL,LATION _X YUUWZREPAIRm/�;f PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,�� <br /> SEWAGE DISPOSIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LIN PRIVATE DOMESTIC WELL X_ PUBLIC DOMESTIC WELL a :`} <br /> INTENDED USE " .TYPE Or-,'WELL If. CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool I/,Dia. •of Well. Excavation .� <br /> I <br /> -- - <br /> Domestic/priva't r~Drilled Dia.'cof Well Casin 'j <br /> Domestic/publi j 1 Driven � `Gauge�of'Casing <br /> Irrigation •�' ! Gravel Pack Depth of Grout Seal- oe ,_._..., <br /> Cathodic Protection `r -Rotary -Type of Grout <br /> `.I / <br /> Disposal Other `,% Other Information <br /> Geophysical - Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor k ? #€ <br /> Type of Pump. [/"y ! H.P. <br /> PUMP REPLACEMENT: / States Worlt'. ;Done <br /> F <br /> PUMP REPAIR: <br /> / / r State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` ` Approximate Depth <br /> ��- - Describe Material and Procedure <br /> Gil well.-�, ,d� v , <br /> I hereby agree to comply with all laws and r gulations f the-Saff Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY'S <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 CA FORA GROUT INSPECTION <br /> PRIOR TO GRO_WfING ANDA4 SPEC UN. <br /> SIGNED Q TITLE <br /> (DRAW PLOT PLAN ON REVERSE SItff <br /> FOR PtPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY �, DATE f/- Z - �� INSPECTION BY , DATE <br /> _ E H'1426 -. Rev... 1-74 b/7.7 _ 2M A <br />