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�-� SAN JOAQUIN LOCAL`.HEALTI1 DISTRICT <br /> FO1 'OFFICE USE: 1601 E. Hazelton.Ave:,-Stackton, Calif. <br /> Telephone: (209} 456-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS .PERMIT EXPIRES 1.YEAR _FROM'DATE ISSUED Date Issued �-- <br /> (Complete..,In _Triplicate) <br /> I` 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 Joaquin <br /> County Ordinance No. 1862 and the Rules.and .RegulatiEons'•of.,.the San Joaquin Local Health District. <br /> JOB ADDRESS/L®CATION_ !� 9E53 - �� S�C :_c7%v ;: c�rLldTiS� CENSUS TRACT <br /> Owner's-Name 1 �/�t7Vi�e Phone <br /> Address �. _ .. .��' 'ter, _.: w � R . _. .. City Li r. .��n1 <br /> 5 <br /> � xc�/a Phone gc -�07 <br /> Contractor's Name <br /> License <br /> TYPE OF WORK (Check): -NEW WELL /? DEEPEN "/7 RECONDITION .1.7�,DESTRUCTION /-j <br /> PUMP INSTALLATION REPAIR /-7—PUMP wREPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0 .PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (fl <br /> PROPERTY LINE -- PRIVATE DOMESTIC-WELL- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLI_` CONSTRUCTION�SPECIFICATICNS� <br /> Industrial Cable Tool Dia. *of Well Excavation <br /> Domestic/private Drilled Dia." of Well Casing <br /> Domestic/public Driven Gauge i6f Caiing <br /> C Irrigation GravelwPack DepthJof Grout,Seal <br /> Cathodic Protection z,.� Rotary, Type jai Grout` <br /> Disposal _ `Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .• "" <br /> Type of Pump H.P. <br /> �. � J JPC'driour3. ;%!�•� Se-d '� ,�rvJ'T.9LL J/�� cJ e� <br /> PUMP REPLACEMENT: / State Work"Done <br /> ,. , w <br /> PUMP--:REPAIR: "�° /7Stae Work, D-669 <br /> DU. RUCTION OF WELL: Well Diameter 'r �, Approximate Depth <br /> Describe'.Material and Procedure <br /> !. I hereby agree to comply with all lairs. amd 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 VILL CALL FOR"A "GROUT INSPECTION <br /> PRIOR TO GROUT D A F AL SPECTION. <br /> SIGNED I _ TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE;� <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I f. <br /> APPLICATION ACCEPTED BY DATW6P <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I_IVF, NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 'S <br /> E H 1426 . Rev. 1-74 1-74 2M <br />