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— <br /> nF <br /> SAN JOAQUINLOCAL ,REALT11 DISTRICT <br /> FOIACE USE: 1601 E. Hazelton Ave ', 5tackton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (Complete In Triplicate) E� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />• ;� °l 3�o ,�. t{r writ- ' � R <br /> JOB ADDRESS/LOCATION i o *% Htlo �' 17•-rr�r CENSUS TRACT <br /> E ' <br /> Owner`s Name _ Phone // // <br /> Address (70, -/i 4i 1°r �r"i` C� City �C1�Ge� <br /> Contractor's Name ?s++t] i� .�_ License #/j2ZtjfPhone 2,, 74 79 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP�INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT �&7 <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 /> Industrial P Cable Tool Dia. of Well Excavation , <br /> .X Domestic/private t Drilled Dia. of Well Casing ' <br /> + Domestic/public Driven Gauge of Casing <br /> ` Irrigation i Gravel Pack Depth of Grout Seal <br /> i Cathodic Protection i Rotary Type of Grout <br /> Disposal 1 Other _ Other Information <br /> Geophysical Surface Seal Installed-BY: <br /> s • <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump /J! H.P. '?�__ <br /> PUMP REPLACEMENT: /7/- ,State Work-Done 1G� D` ( f��r.•-,� �- irrU s.G/ ,LUQ <br /> PUMP :REPAIR: /W7 !State Work Done <br /> RES:RUCTION 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 theiwell and notify them before putting the-well in-use.. The above i <br /> information is true to the-best of- my kdowledpe and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING D A FINAL I PE Ijfg. <br /> SIGNED TITLE ds-r' { <br /> !/ t J(DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> tt _ E Ii 1426 Rev. 1-74 ' 1-7 4-21,_ <br />